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Declaration of Domicile and Citizenship -
4'75302
TO THE CLERIC OF THE CDZCUIT OOUAT.
ST. LUG 1 E OOUN'1'Y. FiARIDA: - -
This is rep declaration d Domidle sad (~tisenahip is the State d Floeida that I am filing this dy in aooozdanoe. sad is
ooniortattj wttb Section 288.17.1:'lorlda Statute~sj ~y
_ - I was foe r a legal resident e[ < - - • sad I
lG7Vl ltit~
resided ~ ~ .~-/al.N ~ s lI ~ - Howsvee. I haw changed rap domicSe to
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sad am and have been a bens Sde resident o[ the State d Florida siaos dp d
a
I .19~ sad I reside at ~7 •Q'1/~~/`•~'•l.,l
r/r ~ 1 ~ N-.
< tea..t..aN..e.rl
ST. LUG 1 E Fbeids.
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and this statement is to be taken a rep declaration d dtiseasb3p. sexual legal nsidena and domkils is tbs State d Floeida.
IF FOR THE PURPOSE Oi ENROLLING IF POR HOMESTEAD PURPOSES,.
CH I t.OREN I N SCNOOI, Pt.EASE STATE PLEASE CHECKS
THEIR NAMES.
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-!lECOltD 11l•RIFIft1 1-- - -
4'75302
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i I FURTHER CERTIFY that I wID register at mT local address when the registration booms reopen. sad oompiT with ail
other requirements d a bgal readeat d this State.
I FURRIER CERTII~'Y I ve intention to return to foemer domiea7e. sad I intend to remain in
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Florida, permanemir • ~ - -
a•
CDUNT
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~o
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sworn to and subscribed before me this ~ dad d -
ROGER POI TRAS. CLERK OF G IRGUI T CO~iT
ST. LUG i E COUNTY, fLOR 10A -
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_ EPUTY LERK ~~fp~~ ~ -
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