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D~ctar~tian of Domtc~lo ~nd Citizenship
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TO THB CLEitK OF TH~ C1EtCU1T COUR1'. • _
,
• ,,t~~.oLL~f~.__ COUNTY. FLORIDA: _
TAis iu my declatatioa o~ DotakW and CitiaensAip ia tM state ~t Elotida t!?at I am C~ltn` thi~ d~r ~ecordanes, and in '
conlormit~ wit!? Satiioa 22t.IT. Ftorida $tstutet.
.
~ I.vas torm~rly a k`al e~esident o~ l,~s~_ . ~~~'g ` ~ I
~ v C~l~It~ / t~ lSut~l
nsided st ~~-~„5~ ~ No~
wever. I bav~ct~an~ed en~ donucDe ee
1~e~t aaA Nrme~N ~'~r .
and am and ha. e bcen a Goaa fide ~esidtnt af the Slate of F1ori8~ sloct D~ ~ - da~ o[
~ 1! - aad I reside at J~ ~b S~ ~ `S'~~~ ~ ~ •
y.,r tetr~al aa~ MR1
~ /~G' ~ ,~~i~l! L ~ir~~/:/~ counc~. F1or;a•.
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,a~~d this statement is to be takca u my dalatation ot tit~ensld'. ~etwl lspl re~tdence and donda'te ie~ the State ot Flurida. ~
~lo~,~ rrc~ p~~c~,~'ESs ~
I£-fc~r the purp~se of ~rol I inc~ _ p,~, ~X 8 5? 35
children in public screul, please
~race tt~~ir na~nes : ~ ~ F(~
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I 1 Fi3RTHEtt C£ATIFY that i.viU register at rny local addreu w+hen tl~e tttistntion hook~ reopen, and eomplr w itA aU
other requircments of a kgal resident ot this State. "
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~ t FGRTHER CERTIFY that,,~j have no intentioa to return b m~ tormer domic~e. and I 1
~tead to remain in
; ~ ' //q /r/ ~ _ LJ4h~!
_ Count~.
E ' ICic~)
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~ Florida. permaneatl~. ~ ~C 30 ~
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~ S.vorn to and suDxn'bed before cne this _~L,L- da~ Q[ !e~~l~l
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R~sIR PQITR.~S . CIEiLK CIRiCUIT %UR'I . I~ame - print
Sr . LUGIE C(XJI~'TY , FIARIi~ ~
i)er?uty C erTc • -
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