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Decla~bn of. OmnitiltJ l~d Citizenship
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Thb I'; IllY dedall,tiull of Domiule ami Citizenship in the Stale uf Floritla tllllt 1 um filin~ tlus tla)' in accordance
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Sediun '2'22,17,
Florida
Statutes,
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I \\',IS [urmal)' a legal resident of
State
However, I have changed my domicile
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(" ,.. ;!III al'd ''''''l' b'l'I, :1 b'''1I ritl" residellt of the ~;late of Florida since
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I'll!:'\' !'lEH(,E, S,\I:-;T LCClE COUNTY, FLORWA.
all Ihi.' "tak.I,~nt I~ to b,' tuken u,; my tlC<'laration of citizer.s:.ip, actual leg-al l'csidence and Jomicile in the State of Florida,
t In'l'rt I;e;,' a,.)' pertinent facb. such a~ sale of prupl'rty or Lusincss, or relinquishment of empl~ment
,,: ll1rlller ,lumieile, rellloval "f family to new llomide. purchase of homc, ete,)
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I I''l' itTIl E R CLRTl F Y th'1t I will register at my local addresF when the registration books reopen, and comply
\\'1:;, ,,I: , th.'r llquilemcllts uf a legal rcsident of this State,
I Fl:I:TllEI~ CEHTIFY that I have no intention to return to my former domicile. and I intend to remain in
FOlt'!' l'IElt'E, SAC,T UJCn; COUNTY, FLORIDA. permal1ently.
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Notary Public
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~.1y "C~~ll~ion expires
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('I" he l''\ccutl'd in dup:i.'ate a"cl or}ginal filed with Clerk Circuit Court, and duplicate lVith Tax A6SE8llor)
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