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'r0 THE CI.ERK OF THE CIRCUIT COURT.
ST. Ll1G I E Cp~iTy, I~-I,pRIDA;
S~ 35~1
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This is m~ d~ctaration ot Domie~e and Citizenship in tbe State of Florida that I am filtng thIs da~ in accordanoe, and ia
conformit~ ~itD Scction 222.17. Florida Slatutes. ~ -
1 a•as formerl~ a legal resident oi .~o ~^~ o t= l~l~_~ ~. 5 , ~•~~ ~ and I
(G~t~l ~ IStat~l
resided at ~ t~-- ~$.E--~- ~~ . Ho~ever. I bave cbanged m,~ domie~e to
~s•.~c ~a x~~~ - TN
and am and hsve been a bona fide resident oi t6e State of Florida sina Z y' da~ o[
( ~,C_~ o~~. 19$e r
. . and I reside at ~ •~. ~ P.~i~ o kC ~-_
._ ~ ts~~aN,~~
~~ ~- • ~ v c - ~ , ST. L UG i ~E Count~, ~'lor;da.
. ~~~ .
nr.d this statement is to be taken as my declaratioa of c~tiunship. actual Iegal residence and domia7e ia tbe State ot Florida.
- IF FOR TNE PURPOSE OF ENROLLING
CHI~DREN IN SCNOOL~ PlEASE STATE
THEIR NAMES:
IF FOR HOMEStEAD-PU P~SES~'-
PLEASE CHECK:
~
19SI J~t~ 14 A!~ i l~ 27
~~c~e a-;r ~ecarr~fn
Si.IUCII' Cp}~NTY.F( ~.
RcGER PGiiRns
CLEFK Ctn"CUIT CCUn1
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S~ •?541
I F'i1RTF~R CEB1'ff'Y t6at I w~71 register at m~ local ~ddre~~ when the registration boob reopen, and oompl~ witb aD
i o:her rrquirements of a legal resident oi this State.
I FLTRT~~ER CERT~'Y that I hsve no inteation to return to m~ former domieile. and I intend Lo remain in
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~ S~. oro to and snbsrn'bed before me this // da~ cd ~~~~ ~J , t- _ l.~ o~r ~ tiZ d t~ o~ =+ 1` , ',
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~ ROGER Ppl TRAS* CLERK OF G IRCUI T COtfi2T
ST. LUG 1 E COUN7Y, fLOR 1 OA •
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BY: ~
EPUTY L RK
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