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Declaration of Domicile and Citizenship • •i
• ~ 454416 ~ .
ZIO THE (~.ERK OF THE CDLCUIT COURT. .
S'~•, lUG l E Covl~rlr. FIARIDA: ~ ,
`,.~1~is i~ mT deeiarasioo o~i I3amnio'ie ana wiieensoip ins`ne aiaie of i
wrioasbsi I sm o~'iias iii. o+~ is scow.~.~e. aa3 la
ooafarmip with Seetlon 222.17. Florida Statutes.
I wu a legal resident d ~~nT~ l C H -y~ aad I
resided u - However. I havs domia7. to
-
and am and have been a bona Sde resident
d the State d Florida aiaes dad d
il...~. and I reside at ~ O~~- Ln~lil i4-~/ 1'1~
18t~stadL~t
• ~Q i ST. ~.,fiLG ~ _ ST. LUG I E ~~,I,~,, .
. ~a4~
and this statement is to be taken as nr,T declaration d dtizenship, aetud legal residence and .domicile is the State d Florida.
IF FOR THE PURPOSE OP ENROLLING .IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL., PLEASE STATE PLEASE CHECK:
THEIR NAMES.
• ~0~1 ~
OJt1 C ~ 1919 AJG -9 AN !I~ 34
S
RLI
CI ~ppR~~ECTTt~
A.
C~E~ POITRAS
RCtRT GDIUI~J~
RECORD YERIf1E0~
454416
~ I FURTHER CER1Z>F'Y thst I wRl register at mT local sddreu when the registration books reopen. and oomplT with all
other segnirements a[ a legal resident d this State.
~ I FtTRT'HER CERTIFY that I have no intention to return tom former domide. and I intend to remain in
_ T. U C I E _ Count7, ;
_ (CSt~)
Florida. permanend;
• _
=ely j~ S e ~ YA E ~ V
n~
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V - ~i.a.•c l ~ ? ~y
a~.~.r, eLE
D ~iDl~sJr9
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Swam to and snbs~'bed befaTe me this ~ daj d PD .T. .~T. ~1G/ . ~
R A C ERK OF CIRCUIT COURT
. ST. LUG I E COUNTY, f LOR t OA
_ .
BY:
~ EPUTY L K
~ .tom