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Declaration of Domicite and Citizenship ~
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515500
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TO THE CLERR OF THE CIRCUIT OOURT.
ST. LUG 1 E ~~. ~~~;
Tlds 4 m~ deeLrstion oi DomkDe aad Cltisen~hip in tbe Stat~e at Fbrida that I am IDiug tht~ da~ in aooor~aano~. ana b
oonformtt~ witb Sectioa 222.17. I~7ozida Statut~es. '
I~+as formerl~ a legal nsident ot N.~cC -~ G~ , aad I
'~ y~,~ 1W~1 1
resided at _1.~ /~' ~C..1_d~ Ao~vever. I bave eh:nged ~ domidls to.
18teMt ~ad I~a~D~r1 -
and am and bave been a bona fide resident oitbe Sta1a oiFlorida ainoe ~ ;Z da~ d
-1~.~~ and I nade at ;~3_.~'
(8t~..t.nd Numb.rl
F~ ~e,,,. ._ _ ST. LUG i E ~~. ~~
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and this stateme~ is to be tal~en as aq~ deeLratioa o[ eitiunship, ~dNal IOsiI lQS1aE0OE iDd dOIDICLI! ~~0 Stit! QI FJOt~L.
I i fOR THE PURPOSE ~OP ENROLL 1 N6
CHIL~REN IN SCHOOI~ P~EASE STATE
THEIR NAMESS
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IF FOR HOMESTEA~-PURPOSEB~~"
PLEASE CHECK: ~
515500
1.981 f E6 - 2 A!i I~ t 2
F1LE0 cN[ R~CORD~O
S RO~GER POITRAS~
' CIERK CtRCU11 Cf~Ufj~;
Ri:~R'~ ~'~ R:: it~ 0 1j// --
I FIJRT~i CERTlI~'Y t6at I wfll register at aq~ local addnss when tbe tegistratioa boo~s reopen, and eompl~ wltb aD
ot6er nqniremeat~ d a kgal reside~. d t6is State. ~
I FURTSEIt CEAT~,F'Y tliat I have no inteation to retarn to former domie{k. and I Intend to r~emaia ia
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F7otida, permiaenc~,'.
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R~ PO~JRAS, CLERK OF CIRCUIT COC~2T
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~ ST. L 1 E COUNTY, ~'LOR 1 OA • ~.
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