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4b49'74 . - - ~
'FO THE CLERK OF THE CIRCUIT COURT.
S~ . LUG 1 E COUNTY. FIARIDA:
~ 4'his is m~ dedaration of Domide and CStizenship in the State of Florida that I am fliag thin dad is aooordaaot:. and is
` contormitT with Section 2?2.1?, Florida Statutes.
' _
' I wa_s formerly a legal resident of _ ~~'ZLC/L- ~-s-~~ ~ ^ aad I
!(~7) State
resided at - li~'C ~
AoWever. I have clanged m~ domide to
(Street and Number)
and am and have been a bona fide resident of the State of Florida since ~ ~ 1~' daT of
19_~ :nd I reside at J v~~~ S'
. ~stra.t asaNpmbet)
- ~ t,Fit. G.t~ ST . LUG 1 E Count. Florida,
l~il
and this statement is to be taken as m~ declaration of cotizenship, actual legal residence and domide in the State of Florida.
IF FOR THE PURPOSE OF ENROLLING IF FOR HONESTEAD PURPOSES,
CHILDREN IN SCHOOL,: PL EASE STATE PLEASE CHECK:
THEIR NAMES:
1~ ~ ~ ~
~r ~ ~ X919 t:0'! -6 ~u ~ 15 .
• FILED LkL~ t ~ Cr~zf C
~-G
SL LtlCtE CQ.;tf T Y. F1.1.
ROtiER PCITR:.S
CLERiS CIs~CU'? CC v. ,
449'74
r
I FURTHER CERTIFY that I w~ register at mT local address when the registration books reopen, and oomph with aD
other requirements of a legal resident of this State.
I FURTIiEB CERT'IF'Y that I have no intcotion to return to my former domiale. and I intend to remain in
7. U C I E _ CountJ.
_ ICet~) .
Florida, permanenti~.
t* r r
~
Sworn to and svbsa-abed before me this daT of ~ ~--«'t ~ Q ~ ~ ~J~ ~
- >I~a --f- - ~ _ .
_ ~D.19
~ 19 -
ROGER POIIRAS. CLERK OF CIRCUIT COURT ~
ST. LUG1E COUNTY, FLORIDA -
'
BY: ~
EPUTY LERK '
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