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Declaration of Domicile and Citizenship • ~
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100 THE Ci.ERR OF TAE CIItCUTI' COURT.
S~~ LUG 1 E a0Uiti1'i'Y. ~,p~A;
~ `,'l7tis is sq~ dsdaration d Domicile and Cltisenship !n the Stab of Florida that I am Sling thin dy is acoardanos. and is
_ coafoamit,T wKb Seetian 221.17. h7orida Statutes.
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r- I was i rn~e a legal resident o[ l~
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resided at o2 Q e ~ H 5 ~ - flowerer. I have ehang~ed ~ domie~s b
ISt~wt and Noob~ .
and am and have been a bona fide resident d the Stab d Florida since ~ q / ~7 ~
i!_~ and I reside at 3 17 /~e it ~ wOO G>I ~of .
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' and this statemeat b b be taken as aq dec]antion d eitisenship. actual legal residence and domicile in the State d Florida.
IF FOR THE PuRP05E Of ENROLLING If FOR HOMESTEAD PURPOSES,
CHILOREti tN SCHOOt.r PLEASE STATE PLEASE CHECK2
THEIR NAMES:
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LUC~MC~T •Af~A-
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- RECORD YERIFIEO
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1 F'UR'PHER CEAITFY that I wiQ register at mT local address when the registration boobs reopen. and oomplT with aD
I other r,egniremente s[ a legal resided of this State.
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I FURTHER CEB1'IFY that I have no intentioa to return to mp former domiefie. and I iatend to amain in
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Fbrida. permanend;
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Sworn to aad snbsm'bed before me this daT d ' l 7 ?17~ud ~ ~c~ i'O~ ~ sr ~-u~ ~ c, F~q
• A.D.19_ 9 33 Asa
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R A C OF C IRGUI T COURT
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ST. LUG 1 E COUNTY, f LOR t DA
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