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'I~hix i~ nty ~I~•c•I;~r:~tiun of I)c~iiiirilr an~l ('ilir~•n,hi~~ in lhi~ Sl:~l: ~~f flc~ricl:~ thal I am filin;, this ~lay ii~
ar«~ntanrr, anil in rc~nfc~rmity ~~~ith Srrtion „_'_.17, I~lurida Statutrs.
1 was formrrly a 1r~.;al resi~l~ nt of ~ and 1 ;
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resi~lyd at - . Ho~~-~vcr, 1 ha~~c ch:in~cd my domirilc to
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and am and have bern a hona ticlc r~sicl~•nt of the State oi l~lorida since day of
, 19__~.~, and 1 msidr at
(Slrrrl and Numbcr)
,~.tnrt..t . u-~' ~ County, rlorida,
.
(cnr)
and this statement is to he taken as my declaration of citizenship, actual kbal residence and domicile in the State
ot ~lorida.
(L?srrl herr any prrlinent faclc, such as sale of pmprrl~ or huciness, ut relinquishment o( employment al formet
dumicJe, rrmo~al of family tu ne~v Jumicile, purch~a~ of Aume, rlc.)
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1 FURTIIER CERTIFY that 1~~~ill rc~ister at my loral address whcn thc re~istration books rcopcn, and
comply with all other rcquirements of a le~al resident of this State.
1 rURTt11:R C~RTIrY ti~at I ha~•c no intcntio:~ to rcturn to my former domicilc, and 1 intcnd to rcmain•in
t-f~ A.~,e, , ~ ~ , County,
rlorida, pcrmanentty: (c~'''~
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S~i•orn to and #ul~~.rili~~l b~ ~orc mr thi: _ a~_ day of
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Niita~y 1'ulrh~ til~lr u( I 1•~n. a t 1 ~t_r
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ao~K ~05 1385
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