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1'hiti is my ~Irrl;~ratic~n ol~ 1)c~micilr an~l Citixrn,hi~~ in lhr St.ii~ ol~ l~lorida that 1 am filin~ tliis day in
accordanrc, an~i iii ccmli~rmity ~vitli Scrtion ~'"_'~.I T, l~lorida St.Uutrs.
1 was fonncrly a Ir~al resi~lrnt of ~ - , - and 1
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residcd at _~~2~~ ~ ~ .]lo~vcver, 1 havc ch:insrd my domicilc to
(Slrerl an umMr) ~
and am and havc bcc» a bana fidr r~sidrnt of thc Statc uf ~lorida since day o1
19_~~, and 1 resi~ic: at s~l~~ ~~Ct~.21 ~~J U/~
(Slreet and Numbet)
~ ~`-'~C.~~u.~- . -K-~-c-v County, Florida,
(c~~r)
and this statemrnt is to be taken as my deciar:~tion of citizenship, actual legal residence and domicile in the State
ot I=lorida.
(Inseri hert any pcrtineni facts, such as sale of pmpert~• or business, or relinquishmenl of employment at former
domicile. remo~al uf family to nr~v Jumicilc, purchax of hume, rte.) i
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F LED AND RECOROEO ~ -
S~.IUCIE COUNTY flA. ~
ROCER POITRAS.
CLERK CIRCUIT COURT
RECORQ YERlFIED~~~
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I FURTHER CERTIFti' that I will reeister at my local address when the rrgistration books reopen, and ;
comply with all other mquirements of a le~al resident of this State.
i
I TURTHI:R CERTIrY tFat ! ha~~e no intention to return to my former domicile, and 1 intcnd to remain in ~
~ 1`~~2-C~~ , , County, ~
Florida, pcrmanrntl~~: (c~ir)
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~ .5~vorn tn;ft~d:s~fisrrihrd hcforc mr this day of
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G~4 A.!). 192~-
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