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TO THE CLERK OF THE CIRCUIT OOURT.
ST. LUG I E pp~Ty. ~,p~w; ' .
T6is It my deelaratian oi Domielle and Citiunship in tbe StaLa ot Florida that I am 51ia~ thts d~ in aaordanoe. and is
cenformit~ ~ritb Seetion 2?2.17, Fiori~a Statutes. ~ . _
I w as formerlq a Iega] resid nt of 'r~~~~ , ~~~ ~/~t%~ ~a j
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resided st ~~~'~ c`f''"',~' fJ1't_` Ho~rever.I6ave ehanged m,~ domie7e to
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and am aad ba~ e been a bona fide resident oi tDe State of Florida sina ~~' ~ ~-- da~ d
19 -~'~ , a.od I reside at ~~ • L~~ '~fJa ,( t~J~"
iStreet ud Numba~
~ o,' i <~T.~ .L u Cl~~ ST. LUG 1 E Count~.Florida.
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and this statemeat is to be taken as m~ deelaration of cititenship. actual legal residenee and domia'le in tbe St~te of Florida.
" IF i0R THE PURPOSE OF ENROLLlNG
CH 1 L DREN 1 N SCHOOL~ P1. EASE STATE
THEtR NAMESS
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IP FOR HONESTEAD-PURPOSES~~-
P~EASE CHECK: ~
I FURTHER CER1'ffY tLat I w~71 register at m~ local address when the rrgistration books reopen. and campl~ witL aD
o:~er requirements ot a 1ega1 resident oi this StaLe.
I FUItTRER CERTg'Y that I have no inlention to rttnra to m~ former domie~e. and I intend to remain ia
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Florida. permanenii;. ~
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~Addr~s~
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1981 JA!~ 29 AN ii~ SS
FILEC ~Nf ~! CO~tUrC
Sf.LUCIf COUN1Y.f;A
ROGER POIiRe'.S '
CLERK ClRCU:1 r~~
't[~(~!"~!i \'{ q r•• n
515190
S R orn to and sobsm'bed befor~e me this °Z 9~ da~ a[
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ROGER POI TRAS* CLERK OF' C IRGUI T COCdi2T
ST. LUG 1 E GOUNTY, f LOR 1 OA • ~
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, bE PUTY l.LERK
C~t-e r .
- g~ 347 PA~f 1709
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