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Declaratiw~ R~~tc~~~~ fiti?;enahip
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III '1 Ill,; :.;TATE AND ('Oll:-JTY TA.'; A~:-;ES~Olt,
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Thi~ I'; IllY Ikd,"at;oll of Domic-ile ar~(1 Citizenship in
thl' Stutl' uf Florida thut I am filing this day in accordanCE:
a:,,1 !I, ....II\;.III'lly with (:hnp:l'r ~~'!, Sl.'dioJl 222.17, Florida Slatull's,
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I w,,~ 1011l\l.rly a l"~al lesidenl of
Cr.:..: l'lc s ton
(t:ity)
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State
.. i 1 I"t.' Ill.d at
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I :.;, n.~t a"d :-.lumber)
Ilowevcr, I havc chanKcd my domicile
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111'.1 ":I"l' bl{'1I :, h.'1.1I C,lt. les;,'j'nl of tht' S:nle of Florida SllIet'
17th
day of
, ,r' ey ,l'll '-:: l"J
I:'_~ and 1 reside at
4210 ~
lorl ~~CIl
L ILC_
(Steet and Numbor)
(01:'1' 1'1 EH(, E, :-'\1:"\'1' LlTlE ('Oil NTY, FLOl\IUA,
" : 'j", ',,:,',"Ul" to hl' lakl'1I ns my Ile<:\arntioJl of ::itizenship, actual le~1I1 rcsidence dild domicile in the State of Florida,
111i "It le,l' any pertillent fad~, sueh n~ salc of plopl'rty or business, or relinquishment of employment
;!! f.,r'IlI'1 dnmieilt,. rc'nlllval I,f family to new domicle, purchase of hon;e, etc,;
:::;i.~l:r.iL.~ 3ili.:;:lE," hnn .li11i:::,;;~s in ~11C: 2nd -;:t",Je
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f!Lrr"; .\ !,~r RECQ;~DEG
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r' Official Record '100K
ISS] FE] 25 1;;-\ 10: 09
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j. t ::.. II E I: , :,In II Y Lila 1 I will rt';:ist('r at my local audres3 when the registration books reopen, and comply
\ ,: 11 !Ip I 1'-I!liil't.'llil.t1t~ Lf a ll'~al resident of thi:\ State.
I lI'I\TIlEH c".:Hi'll'Y that! have n.) intention to rdurn to my former domic'le, and I intend to remain in
1'1)1:1' 1'111:11-:. :-;.\I~T !.I'c'n: COU:-JTY. FLORIDA, permR'lcntly.
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i.;(j ry ,F r it e
(Address)
.c.'., : 'n ",..1 ,..L'('ld,,',! I..,..". me tI:is
~_~.~th. <lay of
'. Febru~rv
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,19 03
1:1)(; I':I( I'OITI(AS
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Notary Public
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My' ;CommissioT\ expires
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1'(" '.C' e~, "'It, d ill duplirale and vrildnal
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filed-;i~li :C~~k' Circuit.
Court, and duplicate with Tax A.8,see8Qr)