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ec~a~ a u~ vas ~~ici~e ai ~u ~t•~izens#~ip
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- ~ 4'7062'7 •
'FO TILE t~.ERK OF THE CIRCUIT COURT. - !
S~ LUG 1 E CovN't'Y. FI,ORmw:
- ~ ~ Docoin'Is sand ~tiseaship is the State d F7acida that I am ~i this ~T is aeoordanc~e. cad is
` This is mT
mnformih with S~ioa 2?Z.17. Flazida SLtntes.
?~a~~ ~ ~ ~ ~~w yoR~ andl
- I was for_mctl a kgal resident d 171 . t~~
resided ~ go y ~ f - Aowever. I bans chanced my domiesje to
~ ISt.set cad Itaeb.lf
3 a dad d
and am and hate bean a bona fide resident of the State d Florida sin~eq
/t/ a 19 ~ ~ - cad I reside at _ / ~y / /~~i¢ f ~ a
1lta..r.adliasbtl
S % `U C ~ ST. LUG i E Couat~.
T
tc~,?,
and this statement is to be tal~en as m~ decLratioa os citizenship. actual legal residence and dome is the State d T•77orida.
- tI: FOR HONESTEAD PURPOSES,
IF FOR THE PURPOSE Of ENROLEtNG PLEASE CHECK:
CHit.DREN IN SCHOOI~ -PLEASE STATE
THEIR NAMES:
~°T9 C~EC 26 ~ ~ 50
FilEO I?k0 R~COiyEU
S RO~GE~
POITRAS `
• CLERK CIRCUIT COUR
• ~!~ltl YERIFtf~
4'7062`7 -
i
I
i
that I w~ register at m7 loch address when the registration boobs reopen. and oomph with al!
I FURTHER CF~1"ff'Y
other re9nvement+ d a legal resided of this State.
r that I Dave ao intcotion to return to m~ former domicile. and I intend to ~~tJ• '
I FURT~ 7 U C I E
-
_ lCa~l .
Florida. permaaeaui-
• ~ ~ ~ - -
yy
1 ~ - cNama
Y+ - F 1
• ,j y ~ , iAddsmsl - .
_ •
Swop Lo cad sabsaribed befart me this (D ~7 ~ -
• ~ C ~ A.D.19_.~_ ~ ~ eYL ~ S~
~ . 79
R~rq POITRAS. CLFRK OF G iRCUI T COURT _ - . _ -
ST . LUG 1 E CO<fNTY, f LOR 1 O - .
CPIITY l.l_ERK -