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St4513
7'O TNE CLERK OF THE CIRCUIT COURT.
_ ST. L UG 1 E covrrr~r. ~,oRmA: .~
This is m~ declsration oi Domic~e and Citizenship in the SLaLe oi Florids that I am fling this da~ in accordance, and ~n
co~formit~ aitb Sectioa 222.17. Florida StatuLes. ~ -
I a~as lormerls a legal resideat of ' ~ ~ ~~ ~'~~ , ~ ~~ •- , anBI
. ICa71 iSt~~
msidedat ='-~ "~•irv~c~~~ T'c~c, ': HoRe~er.Ihaveebangc~mydomic7eto
(S•,rcrt and Nmaber)
P r. d am and ha~ e been a bona Lde resident oi tl,e State of F7orida since -~~ t~' • day e[
- - c.' ~~~.,c~ ,197t3 andIresideat ~'~Fi5 ~:' Zi:-1'v `,t~t
(Street e~dNu~beM
I?oz t;t, i.uc ~e ST. LUG 1 E
, Count~, Florida,
IG~t7)
and this statement is tobe taken rs my deelaration of atizenship. actuallegal residence and domica7e in t~e State of Florida.
" IF' FOR THE PURPOSE OF ENROLLING
CHIIDREN IN SCHOOL~ PlEASE STATE
T NE 1 R NIIMES:
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514513
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I I FURTFiEB CERTg'Y that I v~11 register at my local address when the registration books reopen, and eompl~ v~itb all
i c_her requirements oi a lega1 resident of this State.
I
~ I FURTHER CERTIF'Y thst I have ao inteation to return to m~ foimer domie.~e. and I intend to remain in
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S~. o: n to and subscn'bed before me thi~s ~ ~~ di~ ai
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R~JGER POI TRAS. GLERK OF C IRCUI T COCde'2T
; ST. LUG i E GOUNTY, FLOR 1 OA •
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~' `` LEPUTY I.~ERK
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IP FOR HOHESTEAD PURPOSESi~~
PLEASE GHECK;
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