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is ~ dedaratiow d Demieita grid ie the State d l~osida tkat I as ~ finis d4 is'sooott+dwoe. ad L
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dd at.. co - Hvwewt~ Ilu?w eLaajsd ap doo~Mt~
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.edam sad ~rre beam a bwn 8di: se~ddest dthe Ststt d Florida siaoe ~Td
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and tins statement is to be takes as aq deelarat;oe d dtisens6~ip, ae4tal >QEat resideon and dosoid~e b the State d I7arida.
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If FOR THE ?URPOSE Oi EHROLLiNG SIP FOR HOMESTEAD P!lRPOSES~
CMtLDREN IN SCHOOL~•PLEASE STATE PLEASE CHECK:
TME1R NAMESt -
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ILERK C~lt(~ATC~JR
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I F[JRT~ (~RTiFY ltst I wiII sepstes st mT local address when the regisErstion boots raipea. and oompiT with ail
d>,rr regahemeats d a legal resident d this State.
I F[IAT81~ CF:RTg'Y that I lure m itottaatioa to retnra tom former domirs'k. sad I intend to remain is
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Florida. permaneat~,: - - ~ -
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