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4'x'00036 -
TO THE tt.ERR OF T~ G'IIICUIT OOURT.
3~.. LUG i E OOVN'1'Y. FLORIDA:
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'This is ~ declaration o[ T~amieDe and (~tiseaship is ebe Ststa aI Fbrida that I am ~i this dq am :ma~daadr. and is
conformiy wits Sed3aa 2?Z.IT. Fsosida Statutes.
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- I was i~ a kcal resident a[ -
resided at lj J ~C7 - Aowmrer. I luw ebanaed nq domio'M to
t8trwt aaa Nove.rl - -
and amand b_ awe been a bona fide resident d the State of Florida ninon ~G ~7 d •
19~ and I reside at ~6Q~ /7~7~. U ~IDah ~1
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and this s4tement is do be taken as m~ declaration d dtisenship, actual legal residence and domin'le in the State d Florida.
IF FOR THE PURPOSE Oi ENROLLfNG IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL,-PLEASE STATE PLEASE CHECKS
THEIR NANESS
~ FILEn ~ti ~~EO
. ST. LLi.. rlA.
R
- DEC 19 12 49 P~1 r19
4'0036 ~ .
I F[JRTIiER CF.R11F7C that I wtli register at m7 local address when the registration books reopen. and oomplT with aD
other regnirementa d a legal resident of this State. '
' I ~JRZ'l~ that I have no intention to return to m~ former domicfie. and I intend to remain in ,
T. U C I E _ Couat~, a
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Florida. permanents;.
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Sworn Lo and suhsai'bed before me this ~ ~ daF d • I P~~~ e / G .
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ROGER POITRAS. CLERK OF' CIRCUIT COURT .
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ST. LUGIE COUNTY, fLOR10A -
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EPUTY IERK
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