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- Declaration o~'~~'Citizenship
_ TO THE STATE ANA COUNTY TA% - ASSE.'18OIi.
ar. 1~a oovNTY, I+tioR>ma: .
This is my decLration of Domicile snd Citisenship in the State of Florida that I am fllin~ this day in
accordance. and in conformity with Chapter 222, Section 222.17, Florida Statutes.
COPY.
I waa formerly a legal resident of--____~3'~T~ _---------------------------------_. -_ --------(State)- ------
(cia)
11 Conts4t Drir• - However, I have chaffed my domicile
and I resided at___----__-- ----__...__--------------------- --~ ' •--
------------- ----------- e ,.
(srz..t aaa Nmnb~) i±~d
to and am and have been a bona retie res.3anC Csi we ~ia-,e o: r~;~~ - °``.'r ----- duY of
--------Q4~e4~!>R! -_-_--------------, 18 ~ , and I reside ~.L____- l~'L_~4~1~4__ ~~enlte _-__-____________________--
($trest sad Nnmb~r)
_ - -_-____-~ ?fit Pi a~o• ~t . Lnio i e _County, Florida,
((~*.YD
and this atateament is to be taL-en as my declaration of citizenship, actual leSal residence and domicile in
_ the State o! Florida. ~~yy
i rmer domkila remve~a~oi famib to taw domie~s~P o~ Lose. ~r;lingnisLment a~ employment +t
J~CJ~
and comvb-~ ~ er requirements ofof a legal reaid~t~thia gtate, hen the registration boo~Ca reopen,
T FiTR4'HER CERTIFY that I have no intention to return to ap- former domicile. and I intend to remain
~ ?ort pi~ra• 8t. Laai• ____ _~,~-, i+'lorlda,
__~,
(cat,)
- Patrioi• s. lt.~ia '
- _ tAdtre..)
sworn to snd sub~~db4r~c:+s ms this...~~_dsy a~
J~ 'rah': •~ ~~~ ~~ A. D. 18~X
•!~i.
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(1b be ~ . ~:. ~ . , ~ ~liiaba a~ oei~bal siei with GSee1t Qe~edt t:MURf. a~ d~iats with 'Pau AeMMOC)
a.wu aeppll Cw, pfut Ck'i. Ifs. i