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'Tbis is my declAration oP Domicile ar,d Citizenship in the State of F7orida that I am filin~. this day in
accordance, and in confor.nity w:th Chapter 222. Sectian 222.1?. Floricta Statutes. ~
I was fo.~erly u:egal :esi~L;~t of_~~a~'.T ~AJ/r`~~?GTo~/ N~~ yaie~........_.
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and Z resic:~:d ::t.__. S TI'r A M B o q r ~.y~ However. I have changed my domicile R
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(Sirect ond :~iurnbor}
to a~~d am ~.nd h.?v~ bcen a bona 4uo rc:i+i~cnt ot the SLatc of I~`ioricla sinco.._~~~_.._..__1.2.~....._.. day ot '
~~A~/~(ir~2 Y__._._...._......_... 1J~.~., ancl I reside at~s?.aC..~.~+t~.Q.._. .
.r (5treot and \iumber) ~ ~
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(Cily)
;~~~ct Lhis st:?tement is to be talcen as my dec2:~rs?tion o; citi;~enship. actuAl legal re~idcnce and domicile in
tr.o State of I~'lorida.
(Inscri F~.ere aoy rertinent facta. soch ws aelo oi propcrty or bueincas. or rolinq~iahmant oi w~aploymaut wt
iormor domicilo. removn3 oi faraiiy to new don~icilo. purchuao o! homo, eta) •
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GEmC~~i4 /97 Y ~u/IC/~~,f~C OF .Cr4-~t/O ~Ro~PT~'~ ~ Y ~7EcL~~'AT"~e.?
~ pf" pes.~ic~~F .JNt~ c..si ~~.vs,y,P i~v %.~Y',E sn~r.c oF f'~c~RiOA , ~
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. iT. ~~CiE COIJMTY~
RCCEF PORRAS '
CLEA[ C..:CUIT COYRt ~
RECORO vER~F~ED ~
~ . FEe li 2 ~9 PM '71 ~
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i l~ i1,t;.1i~:R C~~::TQ~'Y Lhat I~vill regi:~lc. aL my ioc:+l :utdreKS when the registration booke reopen;:
:.nci eamp3y v?:th all other rec;uirenjer.ts o: a:e~ai rr.si~;ent o: this State.
1 I~'U;tTIIEP. CERTII~'Y t;iat I have no intent+ori to r~~ar» to rny former dorr?iciio, s?nd I i~:tcnd to rern~ii~
u;._~Q._.'~_3~w~1irS~~.3~...._...---._.~.._~_._.__.___, ._..~.~r?:o:='~.~._.._-------__----------------------County, I~'lurici.z~:
• (Cicy)
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i~ ~ J':~~1 ~•it}, r-~,.r:; (;ir~•uil ~'~~u~t. s~~~~l d~, ~ii~~nw with T~~x A~so~aor) '
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