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'x0 THE CLERK OF THE CIRCUIT COURT. l~ $•~s~ -
ST-. LUG 1 E COUNTY. FZARIDA: ~ .
~ 4'bis is uq declaration of Domici)e and G~tIzeasbip is the State of Florida that I am lilin~ this dad is accordance, aad•ia
_ conformity ~vitb Section 271.17. Fbrida Statutes. -
I was former) a legal resident a! y /R ~/Pl~D~! and I
resided at C C f~71 Aowever. l b:ve than my doanie~e to f
/TD C4 ~ - ged
(Street and Num~esi -
and am and Nava been a bona fide resident of the State of Florida since T~ dad of
f
.,~~,~/~•5.,~ ,19.1 L.. and 1 reside at I ~I S ~ld ~/~G f~F
ft3treet and Nt>m
~z-- ~~~~E ~ ST. LUG ! E County, Florida,
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and this statement is to be taken as my declaration of citizenship, actual kgal residence and domicile in the State of Florida.
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IF FOR-THE PURPOSE OF ENROLLING- IF FOR H.ONESTEAD PURPOSES, ~
CHILDREN IN 5CHOOL, Pt.EASE STATE PLEASE CHECK: ~ '
THEIR NAMES: ~
~ -
,~~Q, T R I C {A l/~g n! D1iR f!G
y jZE~/ ~;5;~
.1L1~.Kl2c=,PHEY~ .
1.
~9~911U6 20 AR ~ 52 .
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arc dRf~T t~T ~
,~E~ORfI VERIFIEQ
~
I FURTHER CERTIFY that I will register at my local address when the registratiaa books reopen, a.nd comply with all
other requirements of a legal~resident of this State.
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I FURTHER CERTIFY that I have ao intention to return to my former domic~e. and I intend to remain in
~ _ _ . T U t: l E County.
_ tCit~) .
F'torida. permanents;.
- •-~~~~---B-T---~%~!'~~-sue-
(Name)
i9~s ~l/re~?~rv6 ,~,~E
f Address)
S orn to and sobscalbed before me this ~ day of ~_•SQC,
t ~
A 3 3 ~ 5 ~
_ ~ A.D.19
~ ~1 ' _ . .
HOt ER PO TRaS -CLERK OF C 1 RGU I T GOlk2T `~~~..~~t*~'.,~'~r~~i~~~~ ~ .
. ST. LUG 1 E COUNTY, f LOR 1 DA ~ '
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6. ~ ~ .~=i.
~~F 525
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