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Declaration of Domicile and Citizenship y'
S].03'7ti
TO THE CLERK OF THE CIRCUIT OOURT.
ST. LUG 1 E COV~y, p3,p~A;
This 4 m, derLratioa d DomicDs and Citisenship io the State d Florida that I am ~ this dq is aooordanoe. aad in
conio~rmit, with Section ?12.17. Florida
I was fon~aerl a legal resident d ~ c/.~+ and I
y ~ ~ IClgl tetsa)
resided at 9 / 8 0.~--o-tL _ 8owee:. I have eLanged mT domie~e to
l8t~st red N~Drr)
and am app have been abonaEderesident dthestate dFbrida since ~-'~ !~ - da, d
ill ~ 0.. and I reside at
tcw~
18t~t sad NsoD~N
ST. LUG i E ~~, I,~,.da,
and this statement is to be taken as m, declaration d eitirenship. actual legal residence and domieDe in the State d Florida.
" I F FOR THE PURPOSE OF ENROt.t.ING
CHILDREN IN SCHOOL, PLEASE STATE
THEIR NAMESS
.~
IF FOR NOMESTEAD PURPOSES,
PLEASE CHECKS
I9~ OEC 12 PM 12 41
FILED ANC FECORD[D
Si.LUC1E COUMTY.FI A.
RCGER POITRAS
ttERK CIRCIN? COtfRji
S1n3'7b
I FiJR1Z~ CERTTFY that I will register at m7 loaf address when the registration boob reopen. and ~Pb with ail
other regnireme~s d a legal resident d this State.
I F[JRTHER CERTD~'Y that I have so int~eation to return to former domicile. and I intend to remain in
UCIE ,~T~
Iahl -
Florida. perma>xml;.
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Swor>o to and.ub.edbea before me this ~_ aa, d 3~N S ~ rr ~ ~ fI C- n ~, /~ / A ~ ~ ~/S ~'
-~- A.D.i~~ .
ROGER PO I TRAS. CLERK OF CIRCUIT ~Ot~tT
:~.
ST. LUG 1 E COUNTY, f LOR 1 OA
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EPUTY LERK
Inc - - , -
AGO Farm 71-22