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Qeclaraton of Qa~n~a~?~ and ~~~~~zenship
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456061 f
TO THE CLERK OF THE CIRCUIT COURT. .
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S~-. LUG 1 E COUNTY. FLORIDA:
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~ This is ap dee3aratioa o[ Do~mieile and G`ltisanship in the State ai Fbrida that I am flint this da,T in aooordanoe, and is
_ ooniormit,F wltb Seetioa 22Z.1T. Florida Sbtutes.
I -was i~ a kgal resident of a A l)F n GI ~ ~ ~Y~ ~ _ ~ • J . ~l R_. and I
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resided at v~ `7 ~o a ~ J However. I bave cbanEed m~ domi~7a to
18s~aw aed Nnmb~ -
and amend have beea abona Sderesident tithe State of Florida ainee ~,1~._ ~ e ~ ~ - ~7 d
J1 1
r 19_. and I reside at ~ ~-3 l(Er ~l,JO d ~ ~ ~ f
ISv..t aaeN.mbal
O~ f ~t l.C G I C _ ST. LUG 1 E Conn. Florida. .
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. and this statement is to be Wren as ~ dec]aration a[ dtizenship, setual legal residence and domicile in the State at Florida.
IF FOR THE PURPOSE Oi ENROLLING IF FOR HOMESTEAD PURPOSES,
CHIIOREN IN SCHOOL, PLEASE STATE PLEASE CHECK: ~ i
THEIR NAMES: ~
. - 4!~~6061
1919 A,1~ 23 PK I~ 19
ST~!lCIE
COUIITY ~ilA.
~tOtiE:R POITRAS
CLERK CIRCIiiT COURT
- - RECORD VERIFIEO__
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I FUR1~R CERTIFY that I.~n11 register at m~ local address when the registration books reopen. aad ~mPl7 with aD
other r~egniremenb d a kgal resided of this State.
I F[1RTI~R CER1'1~'Y that I have no intention to return to mF former donriale. and I intend to remain in
_ ICit~) _
Fbrids. permaaend;
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YT`s
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•~Ct7r.jY ~~~r
~ IAdd,..rl
Swot1 to fad tObsrJibed before me this dq of I
- - A.~.19; 79 ~ - - ,
R C K OF C I RGt11 T COURT
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ST. LLlG 1 E GOUN7Y, FLOR 1 _ -
BY: ~ B(1~K3~5 P~GF
• - PUTY LERK
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