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Tp TU~ CI,~;ItIC Ol~~ TlIE CittClrt~r counT, ~~~''76~
ST. ~UC 1 E COUNTY,.I~'LORIDA:.
' This ~s my declnration ot nomicilo and Citizenshi}~ in lhe State o[ Floridn thnt I am Iilins this dny in accordanco, nnd in
conformity willi Sc~ctio~ 22«.17~ I~'lorida SlAlutes, ~ '
1 wAS formcr~ n Ic~al residcnt oi ` l~ G~• and I
" lCity (St,te)
resided at ~ ~~`Z~ r^ e . I~owover. I ha~~c rhangcd my doraicile to
(Street and Nu:nDori ~
And nm and havc bcen a bona f ide resident oi ihc Slnte of Flurida since ~-~~L.~ ~ day oi
snd I residc at l ~ 1~~ ~
~19 ,
(Slroet and NumDcr) ~i
L i P S~T . L.UG 1 E Counl) ~ I~'lorida,
(city)
~nd ihis statemenl is to bc laken as my declaration of citizenship, r.ctuul lega) residence nnd dotnicile in the State of I'luridn. -
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IF FOR YNk: PURPOSE OE' ENROLI.ING . IF FOR NOME~TEAD PURPOSf.5~ :
t.
CHII.DRCt1 (N SCHOOL~ PIEASE STA7E Pl.EA5E CHECK: ~
~ THE (R I~A~~tES: ~
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_ ' F L!0 AliO aECORDED '
S~..tUCtE COUNTY ftA. ~t~U t
- lIOGEA POtTRAS ~ ,
~ ~ _ GIERK OIRCUtT COURT f,
- ' ' RECORO VERIFtE~ ~
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- 28 1l Za AM'~5
f ~ ~ ~~.9'76~
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I FUItTlIT;R CT:RTIF~' that I will rcgi~ter at my~ locat a~ddress w.hen the mfiistrzlion books rcopen, and compl}• witfi all ~
othcr rcquircmr.nts o! a lc~;ai resident of this Statc. _ ~ ~
,
1 FURTIik;t CF.R'fIT`S' bhHt T i~ave no intc-ntion to return lo my formcr domicile, and I inlend to rcrnain in s
7 ST ~-d t; S7 . L U C 1 C , Couuly, :F
lCity) . ~
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SK~orn to an~ sub~cribecl b~fut c r~e [hiY s~ t~ay of ~~",~-f'~' _ ~
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!~__(~rR _P01 T(:/?S,~_ CLE:Ilf: 4F C IRGUt? COt~7T . ~ _
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