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Deciaration of Domicile and Citizenship c~i
4515~2 '
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To ~c~c oF~ c~curroovKr. _ . i
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ST. LUC 1 E ~pUtv~y. ~t,pxIDA: '
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TAis b mp deelarat~ioa a[ Domkil~ aod Citisenshtp in t6e 8tate ot Flo~id~ tbat I am ~ tlds da~ is uooedana. aad in ?
coafocmit~ wtlb Seetioa 228.17. I~7oe~ids 8tatutes. :
~ k8+1 ~=Ll..~--11\ ? C • ~ ~ ~ and I ;
I was f~ a resident o[ .
1Ck71 tet~t~1 i
resided at 1. ~ y ~ E~'~ 5 ~ 0~~ - Aowever. I bsv~ ehaoaed m,~ domie~s to
IBteMt ~sd N~Mr) ' '
and am and bave been a boaa Bde sesident at tbe Stat~ d I~7orida sinoe ~+~J d
~ l~ ~--~_,19~ and I reside at ~ ~ L M e f1~ U~ ply ~ A N~ S H 1G~ K tS
(BtrMt atl No~b~e1
Q o(ZT 'C 1~~5 c, 1 C , ST. LUG i E ~h. ;
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and tAis statement is to be taken as m,~ declaration a[ eitisenship. actua} kgal naidenoe and domin7e ia tbe 8tate d Flaida.
li FOR THE PURPOSE OP ENROILING Ii FOR HOMESTEAD PUtiPOSES~
CHILDREN IN SCHOOI~ PLEASE STATE PLEASE CHEGK: ~
THEIR NAMESS
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t couHTY f~ a.
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' CLERK CI!iCl'i ~ CC~J~j~T ~Q
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451522
I FUATHEI{ CERTIff'Y that I~l rtigister at m~ loul address wben the registration books nopen, and eompl~ witb all
~ otber reqnin~ents ot a kgal nsident at tL~s State. .
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~ I FUItTHER CERTII~'Y tUat I have no inteation to ntnrn to m~ former domieik. aad I intend to nmain in
_ . U C i E _ Count~~
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~ F7orida. Permanensii • .
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~ Sworn to and snbsert'bed before me this /-3 da o! S ~ ~ ~
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~ A.D.19
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ROGER P01 TRAS. CIERK OF C 1 RCU 1 T COUtT
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ST. LUGIE COUNTY, fLOR1DA ~ ~
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BY:
EPUTY LERK ~ -
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~ 6~3~.2 ~~~21~06
AG(} Ft+rm 71 22
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