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Detlorotion of ,~~3ib~~ifisenship
'I'O TSE STATE AND COUNTY SAX ASS~SOR,
3'P. LIICIS mUNTXa FLORIDA:
This L my dec4rition ad Domkik sad Qtiseaship in the State of Florida that I am ~ this day in
accordance, and in coniora4ity with Chapter 222. Section 222.1?. Florida Sbtntes. ~
I was formerly a legal resWeut of _~IL' ) _ ____ -_(~) _.~._..
and I resided at 3306- 1q., COI~TIt>~ _~_._..8~•_--..-. - _- - AowsvQr, I havt~ rh=se~t env doaaf~
(8tewt cad N>a~bar)
to and am and have been a bona !We resident o! the State of Fiorlds since-------- 30Lh-__--__---_---_._day of
'~~~ _______, 19 a~, and I reside at__~11Nir ~~~. ~ L BoZ 3460_
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~_' i~ ~=' ~-~w~j I.6i~e""wi~4 isBTf
l~'P. FIERCE STe _IACIE w_County, Florida,
------------------- (Cib)
and this statement is to be taken as my declaration of dtitenahip, actual legal residence and domicile in
the State of Florida.
former . ~ ~ ~~ ~ domiew. vats at ~i~e~~t at ~ployawat at
.91210
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I FURTHER CERTIFY that I will register st ~ local address when the registration books reopen,
and comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to ~ former domicile, and I intend to remain
~---------------------------~'• PIRRCIt ------------------------,
(cxh-)
permanently.
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$won bo and `i~lt~ibed before me this--_S~h.--day of
--~T+-I~IIC --------- -_--_~_-- ty. Florida,
------ ,~~i~~.~G~~ ----- --------
(Noma) DOE
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a~-rnra c~"~'°"' Dos
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Cleric
(To bo esocobd in dnyikab and oeigjnal lUed wits Qsh Chesil Coact, cad daslkab wits Tae Asaaaor)
Bowen SapDll Ce., Plant Cltr, )rla.
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