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E~~~kr.~l~~il[(~Il C)ti' t~(~[~11IGIlL' c`~IZC~
TO THE CLERK OF THE CIRCUIT COURT.
ST. Ll1G 1 E ~put~qy, F[,pRIDA; '
1:t~f~;CI1~1~iE~
513~3~
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This is w~ deel~-ratioa oi Domic~e and Citjzenship in the State of Fiorida thd I am filing this da~ in aocordanx. and in
coaformit~ ~itb Section ?22.17. Florida StatuLes. ~ - -
I w~as lormerl~ a legal resident of ~v,i~ s ~~~~~~r +-nd I
`~ lCi-7) (SsaW
residedat.~ ~ :~=~.~r C~~~ rHOaeveT.I6aveebangedtn~domic~eto
IS•.ieet and N~ber) •
end am and l~ave been a bona Gde resident of t6e State oiFlorida sinee /~ da~ d
s ,
~~.~-~ -19-~~ , and I reside st ~/~/~ ~ ~ -
~ ~ ~ ( ,~a Numberl
- ~.~ ~_~ ~ ST. LUG 1 E County.Florias,
ltSt7)
and this statement is to be taken as my deelaration of citizenship. actual 1ega1 residence and domia7e in the SLate oi Florid~,
" IF FOR THE PURPOSE Of ENROLLIMG
CNlL~REN IN SCHOOL~ PIEASE STATE
THE IR N/IMES:
_~~-~ ,~/,
r-
:~~~~_ ~ ~ ~ _~'
I F' FOR HOHESTEIIQ- PURPOSESs ~
PLEASE CHECK2 ~
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F~~En ~~r «~aar.~ t~
5' ~i~~tF ~O~ui!Y.f! ~
FiOGF'_.=LfT:`t~ ~
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513~3~
I FURTHER CERTI~'Y that I w~11 register at m~ local ~ddress when the registration books reopen, and eompl~ ~itb aD
o:her requirements oi ~ legal resident oi t6is State. '
I FURT~IER CEBTII~'Y that I have no intention to retnra to m~ former domie~e, and I intend to remain in
, 5T , L uC 1 E , Count~.
t(St~) _
Fio:ida, permanenti;.
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~ Sa orn to and snbsrnbed befort me this /~ dal ad ~~~~f ~-*'' '~ y~~.r ~
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[ . ~ A.D•- ~ 98~ ~NA ~_ F.'~-~-~ rc
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R4GER PO I iRAS* CLERK OF G IRGUI T COC~2T . .
ST. L.UG 1 E GOUNTY, FLOR 1 OA • ~•
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BY: ~~ ~ • . . •, , ~
e Pur LERK '
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~ ' go~346 ~~251~ -~ . j ; -~~
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