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~~cEarafid~ri- of Domicile and• ~itiz~ns~i ,
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4564'~S
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_ S~ Ll1C 1 E o0vt~'t'i. I~'LOItIDS:
~'lUis is sq dedsratioo at Domidie and ~ is the State of Florida that I am ~ tbis dq i, aeoondasoe. ind is
. _ ooatoeraif, wifi Seetior+ YgZ.1T. Florida Statutes. -
- I was t~~aer a kdal rssidsat od 1.~~iA~.e P~U7~D/L ~ if/ ~ C. and I
resided at ~ ~dL (O ~.dfr Howe+rer. I b:w changed mT domicile b
t8v..t.ai Itss~.r1
.and am and haves beaa abeaa fide resideat d the Sta4 atT7orida since daT d
_ 191 - a~ I raaide at ~~/D/ ~!/S7~/ Of ~ ~ 9 ~
, • ~ lea+rc asd 1i..e.el
ST. LUG 1 E ~~,.>j7o~a~ .
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aad this atatemeat is to be taken as np deciaratioo d dtisenship. actual kcal residence and domide in tbs State d Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HOMESTEAD PURPOSESi
CHILDREN IN S[HOOIa PEASE STATE PLEASE CHEtK:
TN 1R NAMES: -
i 4 P
1919 AtlG 28 AK ~ 59
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F ED AND ?Y.F``A. ~
5~~~~RAS
- CLERK CIRCUIT
• RECORD yERiF1E0
4564'78
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I F'I1AT~ CJ;It1'1TR that I w~ resister at mT loc~1 address when the registration booms reopea. asd oomplT with all
other rem at a legal r a[-this State.
I l:'1JIt1~ (~tTII~'Y I have m intention to return to mT former domieSe. and I intend to rtmaia in
uc count.
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ii..eea to sect se+b.~ed before me this _ aa, d - (~~,C
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K ~ IRGU T COURT
ST LUG1E COIfNTY "f'L~R#QA':-.,~ -
BY: a
' EPUTY LERK '
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