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'FD THE CLERK OF THE CIRCUIT COURT. 455493
ST. LUG 1 E ~ovlsrlt, FLORIDA: .
9'his is~my dee]aration of Domica'Ie and Citizenship in the State of Florida that I am fling this day is accordanx. and in
ci,nformity with Section 222.17. Florida Statutes.
,
I was formed a legal resident oI - - and I
• 1~t71 (StaW
resided at 1 _ however. I have changed my domicDe to
(Street aadNumbesl
and am and have been a bona bde resident of the State of Florida since TL day d j
_ 18 ~9 - and I reside at ~Z ~
' ~ l3tieet sad Numbed
~ ~ , a~s.•e~ _ ST. LUG I E County, Florida,
_ tcac~?1
and this statement is to•be taken as my declaration of citizenship. actual legal residence and domia'te in the State of Florida. ~ -
.
Ii FOR THE PURPOSE OF ENROLLING IF FOR HOHESTEA~ PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK:
THEIR NAMES2
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199 IIU6 17 PM ~ 43
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. ~rc+cll~asT cou(r ~ -
• nPCORD VERIFIED
I FURTIiER CF.RTII•'Y that I w~11 mgister at my local address when the registration books reopen. and cornpiy with all
other requirements of s Legal resident of this State.
f -
~ I FURTAER CERTIFY that I-have no intention Lo return to my former domie~e. and I intend to remain in
T U C I E _ _ County,
it"l~,r;da. permanemi~.
,$/-EA 12on/ 1G U~Z
boo ~
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J
(Name) ~
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corn to and subsQtted before the this day of ~ !
_ ~ -
- . A.D.19_ ~ 't
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~()GER POI TRAS,~CL~HK OF CIRCUIT COURT 'b~~r•,.,.~; .
s-:
ST. LUG I E COUNTY, f LOR 1 DA • ~ ~
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. $noK314 Pa~E~487 ~ v ~ • . -
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