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234840
'f0 7~111: S'1~.1~1'I: ~1~~1) ('C)li\'I1' "I~:\\ r\SSI:S~OIt. ~
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"Il~is is my ~Irclarati~~n c~f I~c~mirilr aii~l ('itirrmhi~~ i~~ thr St:~t: c~t f~loricla Ihat I,~m filin,; this da~• in >
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:trcordai~r~•, aiul in ~c~nliinnily ~vith Scrtion ~'~".17, l~lorida Statut~s. ~
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1 was fonncrly a Icral residrnt of ~~-~~N~~-- and 1 i
n (city) (s~atr) ~
rcsidcd at ~~~%?~Fl~~ J~ . Ho~vcvcr, 1 ha~~c ch:~nscd my domicilc to
(SUeat and Kumbr~) i
dnd am and hav~ lsccn a bana fidr r~sidcnt a1' tlic Statc of t~lorida sincc day ol'
~ , and 1 residc at _ o~.3D ~OLlvA- I~~IV~ •
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~ / (Street a~d Nutnbci) '
, ~ LVC/~' County, Florida,
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and this statemrnt is to be taken as my declaration of citi•r.enship, actual l~•gal residence and domicile in the State~
of ~lorida.
(Insert here any prrlinrnt farls, such ac s~lr of pr~.pcrly ar bucincss, ot relinquishmcnl of employmenl al fotmer
domicile. removal ut (a~nily to ne~v domicil~, purch:~~r ot home, rle.)
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aA-T~e,c~ ¢ LyK,J ~~c.~~r A F~ 7 a
234840
~ " FILEO ANO REC~R~EO
. ~ T~ ROCER
Pa TRA
CLEItK CIRCUIT COUI1t
AECORD VERIFIEO.~..~~
A~ 1 3 v9 PM'12
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l FUR"fHf:R CEItTIt=Y th.~t 1~~ill rc~ister at my local address when the rc~istration books reopcn, and
comply with all other requirements of a Ie~al msidrnt of ihis State.
;
1 T'URTI~I:R C~RTI}=Y tl~at I have no intenti~~n to return to my former domicile, and 1 intend to remain in
~f' ~F' L , J ~ ~VCI ~ , County, _
Florida, pcrmanrntly: (c'"~~
JA~ES HICKEY
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t~' (~r~ibccf bcfor. me Ihi: day of
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l~ty Commission c~~,in s- -
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(Tu In e~rcWrd ~n du~,G.a~r rod ~,ni•m.d tdrJ ~~iU~ l'Ir~k l'uru~l ('~~utl. ~ud J~q~laatr ~~ilh Ta~ McrcN~r)
a~ 204 ~ 2~~7
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