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'I~hi~ i. iny ~I.•rl;~ratiun ~?f I)c~n~iiilc ,ui~l ('iliirn>hij~ in lhr SI:~t: ot~ I~luri~la tl~at 1 ant filinr this ~lay in
ac«~r~l;in~•r. ;uul i~~ cunli~rt~iity ~~~ith Sertic~n ,~'.17, 1=1uri~ta St:tlutrs.
1~~•as foriitcrly a Ir;~al rrsi~l.•nt c~i' _(~'IQ.~d~ ~~~''ta~-`~~ and 1
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rr~iclyd at --------~C'C~~~,---------- - lio~vcv~r, 1 ha~~c chan~;cd my domicile to
(Slrral ~n.1 Numbrr)
aiid aiu and havc bccn a hcria fi~r r~sidrnt c~f thc Stafc of l~lorida sincc ~ day of
19----~ and 1 resicle at /l~ ~ Le:~~-e,.
/ (Strret and Numt?cr) ~
G~~~~~ , ~ County, Florida,
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and this stal~ment i~ to be takrn ac my d~claration of citizenship, actual legal resiclence and domicile in the State
of rlorida.
(Insrri here any p.rUn. ot faclc, auch as salr of properly or Aucincss, or rtlinquichment ot employment at fo~met
d~micile, ramo~al of (amily lu new dumirilr, purcha~e of home, rtc_)
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. ~rc'1~1 !i o6 AN'71
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1 FURTlfER CERTIFY that 1~~•iU rc~~ister at my loral address whrn the registration books reopen, and
cotnply with all othcr rrquirements of a Ic,~al residcnt of this Statr.
~ 1 f
URTNI:R CI:RTlI=Y th~t•I ha~•e no intention to return to my tormer dorni:ile, and 1 intend to remain in
~ ,~T - 1`~--c~'x.~ , ~ I , County,
Florida, pcnn:uirntly. (c~`,)
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(N~me)
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~ S~ti~orn to and subxrihrc) brfon mr thi. ~!1
~ay of
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Nulary 1'ubhi Strlr 1 I.~IIJJ ]I I .~f ' ~ - ~ ~ • :
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(To 1„• cuculrJ m Jup6.:d~• ~uJ ~~n;in~) fd.•J ~sith l'Irtk ('i~cuil Cnurl. ~nd Ju ~IN'alr ~r~lh 1•r~ A~ ~ssrK~ ~`N«N''
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