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• 454743
TO THE CLERK OF THE CIRCUIT COURT,
ST. lUC 1 E COUNTY. I'-I,pRmA; .
This is m7 declaratioa of Domicile and Citizeasbip in the State of Florida that I am filinE this dad in accordance. and in _
eonforn~itj with Sedioa 722.1T, Florida Statutes.
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Iwas tormerli slegal resident of ~~1.1CLQtU ! ~ and I
3
resided at ~ ~r'1~.eF..LIJ~ j1~ '~J~ N ~ ~ - However, I have eba6gc•d m~ domieik to
(Street aAdNumber! -
and am and have been a bona fide resident of the State of Florida since u~ ~ ~ day d
19~. and 1 reside at ~Q ~~Pl ~ ~ / 1~
; ~ w y
~L= ST. LUG I Esn~.caaaNemb.rt
- Count, Florida.
ICttj)
and this statement is to be taken as my declaration of citizenship, actual kgal residence and domics'le in the SUte of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSESs
CHILDREN IN SCHOOL PLEASE- STATE PLEASE tHECK:~
THEIR NAMES: _ ~
:~~'43
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a
- ~ ~9t9 AJ~ 3 PN I=- t 1
~~~DP~iR P01 AS ~
ELF tIRCU1T COURT
YERIF1f0
I FURTHER CERTIFY that I will register at my local address aihen the registration books reopen. and comply with all
other requirements of a Legal resident of this State.
I FURTHER CER that I have no intention to return to my former domicUe. and I intend to remain in
T. U C I E _ County,
l(~t~i
F)orida. permanent!;.
x
_ (Name)
i _ ` ~ X 5<y~~ ACA T ~ 3 /1J - F~ fJ. l~~ j/
' ~ IAddress)
Sworn:~o at?d snbsrn'bed before me this ~ day. of - it L' ~ ~ S~
'Q ~ _ Y
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• . c:, Ml? Conwittioa Expires feb. 19. >9~2 . f i
- . CMa~Mti tc <p..tr
/f/Il'~II11 `!t~~
EPUTY LERK .
. ~?k 3~,4 PIKE 1~8~.
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