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~ 514251
TO THE CLERK OF 7'~ CIRCUIT COURT.
ST. LUG 1 E ~;p~ry. ~,p~~;
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This is m~ declaration of Domic~e and Citizeaship in the State of Florida that I am filiag t~fs da~ in aaordanoe. and in
contortnit~ ~itb Scction 222.17. Florida Statutes. .
I w as lormerlq a 1ega1 residen! oi ~~~ . ~/' C/~ ~~~ I
re5caea.t /~a J~ .~l ~v~~ie . ~c~~T - ~suw
, . Ho~ever. I bave cbanged r~ domic7e to
(St:eet aod Nombe~ ' -
and am and bave been a bona fide resident of tbe Stste of Florida sinoe 7-'" ~~~ ~ v da,~ d
,19~ and I reside at ~y ~ ~ 7 ~ ~~ ~% ~ ~~ .
^ (Stree! aad Numbe~
_~_~~~' ~ - , ST. Ll1G 1 E Count~. Florida,
ttsc~)
and this statement is to be ta]cen as my deelaration of citiunship. actnal legal resideace and domicDe in tl~e State of Florida.
' IF FOR TNE PURPOSE-OF ENROILING
CHII~REN IN SCHOOL~ PLEASE STATE
THEIR NANES:
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I FLTRTI~R CERTII~'Y that I v~l register at my local sddress when the registration books reopen. and eompl~ witL aD
:,:t~er requirements ot a legsl resident of this Stste. .
~ I FUBTI~R CER1'ff'Y th:t I have ao inteation to retnrn to m~ former domie~e. and I Intead to remain fe
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f ~'7orida, permsneaii~.
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IF FOR HOMESTEAD~PURPOSES~~-
PI.EASE CHEGK: 1
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I~l JAN 20 A,~ ~ 54
F~~ec Rkc F~co~nro
sr.~ucie couNi Y ri a.
ROGER POITRAS
CLERK C#4~Uti C~L'F~
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S R• orn to an bscn'bed betOre me tbis ~~ da~ o[
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kOG POI ZRAS, ERK OF C 1 RCUI T COCd~T
ST, LUG 1 E COUNTY, FLOR 1 OA •
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