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TO THE CLEF OF THE CIRCUIT COURT.
ST. LUG t E t;ovNTY. FLOI;IDA: -
thax I am sting this ds~ in .ocora.noe. and ~ .
. ~ T6is is-bsT ~•tion d Domiu'le and c~tisenship in the stare d Florrida -
wnform~7 with s~i0° ?22.1T. Ftarida Statute:. ~ • F
1/~~ G~,1 andl
- - I was fo~ Vim' d U tc~1 t~
-Aowever. I have cbang~ u4 do~°~e to
resided at ~ gist and Nmabarl _ • d
t dsy
and am and have been a bona $de resident d the state d Florida since ~ i~~
-19~.._. and I reside at 3a 3 Its
• - ST. LUG 1 E County. Florida.
tts~,~
taken as lmy declaration d dtisenship. actual legal residence and domiale m the State d Florida. _
and this stateme~ is to be _
HE PURPOSE Of ENROLL 1NG L f ~fOR HOMESTEAD PURPOSES
1f fOR T PLEASE CHECK'
t:H1LOREN iN SCNOOL~-PLEASE STATE _
THEIR AMESS
F
ftLEO AEIiQ
R~EC t!U
S ROGER
PpITRAS~
- CLERK CIRWIT C
RECORD VEltIF~E@
~ ~
460288
~ my local address when the ng~tration books reopen. gad aDn°Pl7 ~
I CEZ that I wDl register -
adbe~ d a legal resident d this State.
former domicile. gad I intend to remain in
I ~g~R CEKTIFY the I have no inteation to return to my U C E County.
ttSy) - ?
i
Florida. permanendl. ~
~oU~~rr -
`°~~f ccnhr~~C ~ ! ~ ~ 3 72
u?aa~... 4.
before me this y_°f _ / i j~ - '
Sworn to and snbsers'bed - g- _ / ! ! ! . O
. ~ . ~ ~ A.D.19
~ ~ 0.f/ j~ e YU y d
R pp TRA GLERK OF GiRGUtT GOU2T
ST. LUG l E GOUNT~f, f LOR 1 DA . - .
SY: ~
_ _ EpUTY LERK cc~~ _
~OQOKJ~~ PAGE ~ .4
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