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Declaration of Domicile and Citizenship
5U1049
TO THE CLERK OF THE CIRCUIT OOURT.
ST. LUG 1 E Cpp~y, glpglpA;
This is ap declaration of Domie~e and (~itisenship is the State a[ Florida that I am ~ thb dq in aoooedanoe. and is
ooatarmit~ with Section PTZ.1T.1.7orida Statutes.
I was tom a legal resident d ~ i c ~ Fie ~ ~ ~j ~Y> Sd 0. and I
ltStYl 18ub1
resided at 70 7 ~ ~ t r P h'~ L e n Q - However. I have ebaAged ~ domicile to
tsa..~..arl~? -
and stn and have been a bona Sde resident at the Stab of F'brida since s
~ ~ 6 • ~e~ da7 of
19$~ •and I reside at 3~R ~3 ~ c~ s h e r C~c' .
lStrMt.sa NwaDal
Pa c S~4 • 1.- u ~ ~ e ~ ST. LUG I E c~ti.
~abl
and this statement it to be taken as m7 declaration ad dtisenahip. actual ksal residence and doa~ieils in the Stab at >c'loeida.
! IF FOR THE PURPOSE OP ENROLLING IF FOR HOMESTEAD PURPOSES,
CHILDREN IN SCHOOL, PLEASE STATE PLEASE CHECKS
THEIR NAMESS -
~gernri~ (heo~et~ cer
r-
I9S0 SEP 26 A~; i~ 35
_ e c r .i Y1c~ e~¢ n Se n
fl<<o ~Ne Frcoaoro
S1lUC1 CQUNTY.fiA.
ROG~R POITRAS
CLERK CtRCU1T Cdtl~
' FEf.CR(; t'(R'ilf 1
~ G'
5O1.Q49
I 1•RTA1~R CERTII~'Y that
I w~ •eguter at my local address when the re~tratioo books reopen. and complT with aD ~
other regomments of a legal ~dwt of this State, -
I FURTHER -CEATII~'Y that I have no iatention to return to iacmer dosoiea'k. and I -tntead to remain in
U ~ E ,
ICSc,) _
. Florida. peradanensl; .
s
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t_ J
7
• D lAi8i+M)
Sworn toand sobeeribsd before sse this ~
6 daj aI 110 _ - . ~
A.D.1l~%,. I~'1 is X Mog e n S e ~
i
ROGER PO t TitAS. CLERK OF C tRCUI T CO#~tT . ~ ~ ~ Rqs I~ e ~ C T,~ -
ST. LUG 1 E COUNTY, f LOR t OA
-
BY: c~
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EPUTY t.ERK ~j
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• q
AGO Form 71.22