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4'7'0'750 "
TD TAE Q~ERR OFTAE CgtCUIT OOURT.
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' S'~.. LUG 1 E opvrrrY. FLOxIDA:
This is m~ deduatios of Domic~7e and (~taeaship io the State of Florida that I am fdiag this d:~ ie aooordaaoe. sad to
_ malormitT wlt)t Section 222.17. >:7acida Stata~te:.
I was lornaeri a legal resided a~f /I'I /~~~e e v.~ /l~~ H/c /~.c. •f and I
ii.~t3T - iN<di
resided st • ~P ~ ~ ~ t7+e . ? - flowerer. I haw chanEed m7 domio'1e to
IStrees d NeLerl -
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and am and bare been a bona Bde resident of the State ai Fbrida since ~ 9 ~7 0! 4
19~ 7=' . and I reside at ? / S ~e~o k T~? .e + y ~
- ~ - 19aMt a.d Na~mb.r1
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i« ,P _ ST. LUG I E Conar~.l:7orida. .
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and this statement is to be tal~ea as mT declaration o3 otittnahip, actual Segal resideaoe and domide in the State d Florida.
Ii FOR THE PURPOSE OF ENROIt.~N6 IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCNOOt.,-PLEASE STATE PLEASE CHECK: ~
THEIR NAMES:
4`70'750
- - - !319Q~~27 P;' 23t
I'~ > Partlu?s
anacalea~rtcau~R
Y CER'P]FY that I w~l register at m7 Local address when the registration boobs rzopea. and eumplT with all
' oi.~er requirements d a kg:1 resident oI this State.
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' I FURTHER CERTIFY that I bare no intention to return to_mr former
d~'e~e. and I intend to remain is
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IiSt~)
Florida. permaaemi;.
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S••ora to and st~a~ed b~iote me thi: daF o! ~ %
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R(>GER POITRAS. GLD2K OF G IRGUI T COURT _ , .
ST. LUG 1 E COUNTY, FtOR 1 OA - _ . .
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• EPUTY I.LERK