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Declaration of Domicile and Citiienship
4806S3
TO THE CLERK OF TAE CIRCUITCOURT. -
ST. LUG 1 E ppUT~y~ FLORIDA:
This is up declaration of Domic~7e and Citisenship in the State opt Florida that I a~rn ~ this daT is acoordanoe. and is
oonformit~ with Section 228.17. Florida Statutes. •
I was former a legal resident at r ~~..c L ~ ~ `~i'JG and I
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resided st tc~?rc. Cdr iL However, I have changed m,T domicile to
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end am and have been a bona fide resident of the State of Florida ainoe ~ daj of
per)/
19 0 , end I reside at ~4 •
o.~- T JQ.ce.~ ~ ~~s,.. ST. LUG I E~•~a~~.e.rt -
Count~. Floe3da,
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and this statement h to be Wcen as ap declaration of dti:enship. actual legal reaidenoe and domieRe in the State of Florida.
Ii POR H P RP
- T E U OSE OF ENROt.LING IF FOR HOMESTEAD PURPOSES
CNIt.DREN. IN SCHOOt.e PLEASE STATE PLEASE CHECKS
THEIR NAMES:-
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f
Asa ~ is ~ ~ os F
Eo
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. YERIf~0.
480653
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I F'UR~'i~R CERTIFY that I will register at my local address when the registration books reopen. end oomplj with alt
other regairements of a legal r~esideM of this State.
I F'tJRTHER CERTIFY that I have no intention to return tom former domie7e, and I intend to remain in
CtE ~j,
Florida, permanend;. Q-T ~P~f ~ ~
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cuuNry
tJI ~ ``cOG
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GCE
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sworn to and subaeribea b'eran me a aaT of %~T" ~
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So? 0 ~aUSIAS CT,
ROGER P01 TRASH CLERK OF C iRCUI T COt~FtT
ST. LUG t E COUNTY, ftOR 1 OA ~ -
EPUTY ~LERK '
• _ 800 ~ PAGE
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AGO FormTl•71 `
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