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Declorotion of Domicile and CitizenshipST, ll{CIE CQUNTY, FLA.
TO TI3E STATE AND COUNTY TA% ASSS.9SOA,
~~ Tin COUNTY. FLORIDA:
This is my decLration of Domicile and Citizenship in the State of Florida that I am flling this day in
accordance, snd in conformity with Chapter 271, Section 222.1?. Florida Statutes.
I was formerly a legsl resident of---------PS?RT9,MQTl'~J.-----------------------------. -----------~I-Q ------------------
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and I resided at___--- __-- ~~~~?-1~~b~~S~,_______.-.__-----.-- --------------- ------- However, I have changed my dotntcile
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to and am and have been a bona 13de resident o! the State of Florida since.- _Sad- _ _.. - _ . -. _-__-_day of
.TULY -----------, 19---~ and I reside at----Rt-=-- ~--Bo_z_ 843 ------------ ------------- --------------
----------------------------------
($treet and Nambu)
-----~ ~.~_ sT._I.IICIE----------------------------County. Florida,
(Gtb)
and this statement is to be taken sa my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
lorawr domkil%ra~al o~ taaail7 to now dom~ieUo. pnx~w a~ bom~.oite~~u~ont a~ omploymoat at
9188
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FILtL I~NL ~?~%Ultut~
Rvi~~R POITRAS, Cl~""
S3. IUCIE COUNT'f, FLUE, a~
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I FURTHER CERTIFY that I will register at sty local address when the registration books reopen,
and comply with aU other requirements o! a legal r8sldeat o! this Mate.
I FURTHEB CERTIFY that I have no intention to return to my former domicile, and i intend to remain
;„ 1rT- P'IEkCZ 3T. IA+CIE __ _County, Florida.
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