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Deciarafiion of Qomicile and Citizenship
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511641
TO THE CLERK OF THE CIRCUIT COURT.
ST. lUG 1 E ppU~r. ~,px~A;
This is m~ decluation of Dom~e aad Citisensbip in the Stste o[ ~7orida tbat I am 51iag tlds da~ ia aaordanae. and b
eonformit~ w-itb Scetion 222.17. Florida Statutes. '
I was formerh a Iegal resident ot ^ p.~ - aad I
. ICtU) tSt.W
~~ ~ ^~ t) .# 1 . Ao~revar. I bave changed aU domie~e to
f8tre~at aod N~b~ ~
and aw and bave been a bona Sde resident ottbe Stale oi Florida sinee 15 t h ~ dy d
~ec. 29 ~~ andIraideat 70r~ ~=outh 6th
18t,+at aad Nnmb.r! '
rt . P~erce ST. LUG 1 E ~t~~ ~~
tc~q-1
and this s4temeM is to be taken as m,~ declaration ot e3tiunship, actud kgal residenee and domia'1~ in tbe State o~ Flosida. ,
" IF fOR THE PURPOSE OP ENROLLINC
CHILDREM IN SCHOOI~ PIEASE STATE
THEIR NAMESS
~
Ii POR NOMESTEAD PURPOSES~
PIEASE CHECKS X ~
1980 OEC 24 A!I I1~ S3
F1LE0 RNC FECOBOEp
S( L~!!~C1~ COUNiY.iLA.
~~iK CNtCU ? CCC~7
F~C(1R~, 1'i'FiF {F I~ ~
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511641
I FITRTHER CERTff'Y that I wr~! register at m~ local address ~vben the registration bool~s tsopen. ~d eomp?, wit6 aII
other sequirsments oi a legal reaideat oi tbii S4te.
I FIJRTf~R CERTII~"Y that I bave no intention to return to m~ lormer domin7e. and i fntend to remain in
`. -- ' ST1~UC R E ~~~
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F7orida. permanent~;.
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; Sworo to and snbseribe8 before me this ~/ da~ o[
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~ ROGER PQITRAS* CLERK OF C1RCU1 T COt~2T l~m tj erT 1.. S A,~n p!~
~ ST. Ll1G 1 E COUNTY, f LOR 1 OA •~ ~ pV ~ n r ~H .~, s rq ~ p• ~. ~ ~
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- BY:_;i\\[\,.,. ..~,~ ~. i •- . , ~.~ ;
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' , EP T LERK ~ ~. -
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