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~~~c~'i'tit:'~'r,~~i~i: n~nc~ot,~•i~~~'i~,~x nstit:s~c,it,
- oC ,~c-~~ _ c•~u~~r~~, rt_uitii~.~:
"Chi~ is my ~lrcl:ir:ition c~f I)umirilc :uu! Citirrn;hi~~ in thr Stai: of I~Ic~ri~l:i that t ant filin~ thi~ day in
accontanrc, an~l in cc~nli~rmity ~villt Scrtic~i~ ~'_'.17, Florida St,~tutrs.
t~vas fonncrly a I~ral resid~ nt of ~ , and 1
• (c~~~~) (s~a~
resiilyd at ~ - . Ho~vcvcr, I-havc chan~ed my domicilc to
rrrt and I~umMr) '
and am and havc bccn a hana fidc n•sidrnt of thc Statc uf ~lorida since day ot' }
~ 9 7~ ~ o~/ R e.-~. c~~- ~o. /~c ~
~ , and 1 residc at ~
` w ^ - (Streel and Numbcr)
_ .LY
'y"~N lJ , _L, County, Florida,
(cti~r)
and this statemcnt is to be taken as my declaration of citi~enship, actual legal residenee and domicile in the State
of Florida. -
;
(Insert herr any prrtinrnt facts, such as satr of property or Ausincss, or relinquishmept of employment at tormer
domicile, re~no~al of family to ne~v do~oicile, purchase of home, rlc_)
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234885
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1 FURTHGR CERTIFY th.it 1~vill register at my local address when the rcgistration books rcopen, and ~
cornply with all othcr requirements of a le~al rrsident of this State. . ~
~
I rURTH[~R CGRTIf
Y tl~at 1 ha~•e no intcntion to return to my former domicilc, and 1 intcnd to remain in ~
~ ~-4. ~ ~~-e~ r~ ~ ~°-~-c~~~.cJ +
, , Counly, ,
Florida, pcrmanenUy: (c'''~ ~
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~ - _ ~ o ~-u / 8 8 7-- ~ . ~P.
~ ~ (AdJress)
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~ S~vorn to :uid subsr~ibcd brfor~ mr thi. D- _ day of
. ~,N1...?.
,,,3 ~ e'
~ ~ D. 19 7~ _
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ay .~OI~ I"r ~flJlt U~ I I~HIVJ 01 I JIF~'
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- " ~ ` ' ~ ~ = ~o / 9 7~
My.~tmi~~~i cr1~~j'r?= - -L----
,eA~~ -y ~
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~Tv Ur c~?rculed in Jupli.:~~c ~nJ uni•iu~l fdrJ i1h Clr~k ('~rcuil Coutl. and Jupl~ralr ~~•ilb Tax At~l`<N1f ~
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