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7~0 T~ CLERK OF TILE CIItCUIT OOURT.
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~•`~'l~is it ap dedaratioe d Domkik and Ckisenabip io tLe Stab a[ 1:7orida that t am ~t thb dq is aooo~danoe. and ~
. _ eonformit,T wkL 6ediae 2?5.17. Flosida $tatutea.
Twat akg:treside~at ~?~PP~riGERS ~ln~-~-~ _ EtJ ~D k andl
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resided at `z~ A 1e k E T ST - Nowews. I Law cLangd m~ domieiia to
tst~..t a.a t~lae.d
_ and amend bawbeen abonafide resideat oitheState d F]orida sine ~ ~ d
AV usi- -1l~. and I reside at o~[~ 30 S _ . C ~ESTw_~
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and this stateme~ is to be taken as m~ declaration d eitisenship. actual kgal residence aad domiAe is tbs State d >:7orida.
IF iOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOtr PLEASE STATE PLEASE CHECKS
THEIR NAMES:
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I F[JR17~R t~fg'Y that I wdl reg?ster at m~ heal address when the registration booms reopen. aad e+omPl7 with aD
other regairementa d a legal reaideat d this State.
I FUATI~R CERTIFY that I ha~re no intention to retarn to formes domia'fe, and I intend to remain in
U C 1 E CoontT.
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Sworn to and snbsaibed before me this 7i[~ aa, d T oQT S ~
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K OF' CIRCUIT COURT . ,4 _ L
ST. LUG i E , FLOR 1 W1 f .•l ' ~ , .
BY: ; ~ K:
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