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TD THE CLERK OF THE CIRCUIT COURT. 4s~~s
ST. LUG 1 E oovriTx. FLORIDAs ,
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~`~;9'l~is is nglr deela~tioa of Domia7e and Cittsenship in the State of Florida that I am fiSiag this day io acoordaaoe. and is
_ conforiniiy with Section 222.1T, Florida Statutes.
I suns foTtttef~T a kgal resident of _ ~ Y,.tZ S is ~ Y /~Q J~c _ ,~„g,~ ~e ~ and I
. IC;ty) ~Stat.l
rrsided at - Ao.vever. I have changed my domic~e to
IStsn:t and Numtw)
and am and have been a bona fide resident of the State of Florida since ~ ~D day cI
19~ and I reside at L~ ~:.a.~,~ - ns,,
~ire.t
deb j
_ ~ ST. LUNG I E Couaty,Florida. .
and this statrment is to be taken as my declaration of citizenship, actual legal residence and domia7e in the State of Florida.
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IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECK: 1
.THE 1 R NAMES: i
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1919 AllG 20 PM Z~ 13
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CLERK CdtgNT COURT ~ ,
RECORD VERIFIED ~ +
I r URTHER CERTII~'Y that I wit) register at my local address when the registration books reopen, and complp with all
other requirements of a legal resident of this State.
I FURTHEB CERTIFY that I have no intention to return to m. former domicile. and I intend to remain in
~ T. U C I E ,County,
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i,.„~: ida, permanenci~: -
`~~~GQUNT~,c
~
~
/a ~ U'.~~.~ ,
orn to r.nd subscribed before m~e
this day of .b ,tsn~ T~
y,~~,a, ~ y~~0
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C-_~R POI TRAS, CLERK OF G IRGUI T COURT
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ST. LUGIE COUNTY, FtOR
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' - E UTY LERK
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