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234'799
~ro'riii: ti~r,~~ri~ ~i~i~ c'o~?~~i ~"r,~x nssi:s~uit. .
-CZ ~,t,e,~ ('UU\'i'1'. I~ 1.UK11),1:
'l~his is n»~ ilrrlar;~tion ul~ Uoinicilr :~n~i ('itinn;hi~~ in thr St.~t: c~f (~lori~la th:~t 1 am filin;~ this day in ~
acc~~nlanrr. an~) in cunl~c~rmily ~vitlt Srrtion ''_'_'.17, t~lurid:i Statutrs.
1~vas formcrly a lr~:al residrnt ol' . - and 1
(c~~r) (s~a~~~
resicird at -~..D_3-~e.-~i . Ilo~vcvcr, 1 havc chan~~d m~~ domicilc to
~s~~~c a„a n~
and am and have bccn a bona lidc r~•sicl.nt af tl~c Statc of I~lorida since day ot' !
~ , 19~~..., and 1 residr at .~`'~'/s B~_ 7'~ ~ -
(Strcet~umt?c~)
.
_ ,1~`.~ , 7,,,~. ~!~'D County, Florida,
~c~iY~
and this statemcnt is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inseri here any prrlin.nl facts, such as sale oi p~~~pert.• or Duciness, or reli~quishment of employmenl at former
domicilt. removal of tamily to nc~v dumicile, purct?~x of home, etc.)
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234'799 ,
~~L~tE ~OU~T-YaL~•
IIOCER POCfR ~
c~E~~ c~aCU~T COU~t
RECORO YERIf1ED,~•+r"
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1 FURTI~GR CGRTIrY that I~vill re~istcr at my local address when the registration books reopen, and ~
comply with all other rrquirements of a Ie~al resident of this State. ~
I rURTHI:R CFRTIFY tl~at 1 ha~•e no intention to return to my fornier domicile, and 1 intend to remain in s
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/".~c.t~t.t.c,A , " -u-~-~ , County,
Florida, ~crma~icntly: <<'`'`~
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$wo~i~to,~~~st~~ribcil b~forc mr thi, cl:ry of
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--.__Nulary hulrhr titrte uf 1 h~nJ., at 1 ai_.•
hiy Commi~.iun r~~~irrs _ c~~c..:~_~~__~ ~ ~1~
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(To I~r cuculeJ in Jupli.alc ~nd un~•n~.d tdrJ ailh t'Ir~k Citruil Cuurl. anJ Jupla'~Ir N~~Ifi'fax At~l'tN/f~
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