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Declaration of Domicile and Citiz~nship ~~
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515814
To ~ ~uc oF~ c~cvrroouKr.
ST. LUG I E apv~y. ~,p~A;
T6is is m~ dee]arafioo ~ DomieDe and Gtitissnship in tbe Stat~t at Fbrida tbat I am ~ thV dy in aooordana. and b
oont~ wit6 Seet~oa ~22.17. Flozids Statut~et. ~
I was former~ a kgal resideat o[ _~~ ~ -1.l ~ ~ aad I
q ~~~~~-p 1 (BtaW
resided st _f ~~`' ^~.~ ~ 8o~vever. I bave eban~ed ~ domi~e Eo
- t8trs~t aed N~bK1 - . -
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aad am and 6ave been a bona Sde resident dt6e SW~e atFlorida sinoe # dy d
19~~ ~d i re~de a 1 ~~• 7~~
f~ ~,~,Gt.c..t~ ~ w ST. LUG 1 E~•DeN~ ~~. ~7oaid..
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and t6is statement b to be taken as ap deeluation a[ dtizenship. aetud legal residenoe and domkik jn tbe b'~ate d Flo~ida.
" If FOR TME rURPOSE ~OF ENROLLING
CHI~~REN IN SCMOOL~ P~EASE STATE
THEIR NAMES:
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IF FOR NOMESTEAD~PURP08ESi'-
PLEASE CHE6K: ~
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• ~515814
_ 19~1 fE~ -4 ~i `~ 24
' Fll.[f ~IiC FrCOMOf 0
~ SI.LL~CI COUN1Y.f` A. ~
- . ROG~R FOITRA3
. CCEFK CIF~UfT CCJr7
kF ('t~~"1 ti'-s~i~ ~ , ~~ a
I FtJRT'~R C~ERTII~'Y tbst I wri11 ngister at mf loe~l addn~s wben tbe regist:stion books :eopen, and eompb witb a8
aR6er reqniremeats d a ksal reaide~ cl this State. -
I F~JR1~ CERTg'Y tbat I l,a~e no inteatioo to eetara to iotraer domie~e. and I jntead to remai~ i~
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ROGER P01 TRA$~ C~ERK OF C IRCUI T COC~tT
~ ST. Ll1G i E COtJNTY, FLOR t OA •
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