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'I~U'f{tl: S'1'.1' ' ~ A11) COUN7'Y '1~~1\ ASSI:SSUIt,
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17~i~ is my drrl:~ration c~f t)omicilr aiiJ Citiirii~hip in Ih~ St;it. of fiorida that l am filin~; this day in
accord:in~r, and in conformity ~~~ith Scclion 2'_'?.17, I~lorid:i St:~tutrs. `
1~vas tonncrly a irrai residrnt of ~~s~ ~~~e , and 1
(city) (slatc)
residcd at ~c'"'^ r , liowcvcr, 1 liavc changcd my domiciic to
(Slreel and I~umbr~)
and am and .have bccn a bona fidc n•sidcnt of tl~c State of ~lorida since day of
~u~?~-~~ , 19 7~, and I residc at -~~rnE (Zt- a~ ~c o
~ ~ (Street and Numbet)
«~c~ County, Clorida,
(~cy) ~
and this statement is to be taken as my dectaration of citizensl~ip, actual legal residence and domicile in the State
ot Florida.
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(Init~l hete any pettin.ol fatls, such as sale af property cx Ducincss, or relinquishment o[ employmenl st former
domicile, rentoral ot family to ne~v domicilc. ~~chase o! home, c~c.)
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~ FILEO aND aECORDED
~ ST. ~UC1E iJUNTY FLA.
~ ROCEn "r01TRAS
~ ~ • CLERK Ci:;GUit COURT ~
• ' RECORD vE~+FIEO
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1 FURTI~ER CEIZTIT=Y tl~:~t 1~vill rc~ister at my local address whrn the registration books rcopen, and ;
comply with all otl~er requiremcnts of a Ic~al resident of tl~is St~te. f
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I I'URTNER CER IfY tl~at I lia~•c no intcntion to rcCurn to my tornicr domicilc, and I intcnd to rcmain in ~
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Florida, pcrmancntly: tc~~r) •
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~ . , . (Aadress)
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Sworn tn ~nd•~subscribrd bcforc mc this.~._~ day of
A.D.19~_l_/. ~ ~ .
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. Nulat ~ Idir I~Ir u( 1 I.~nJ~ al t_a~r~•
My Comnti~.tiion rx~~irrs_~=~.6 ~ ~
(Tu I~r eseculrJ in duplir~lr and ui~~ in~l fdrJ ~~ilh l'Ir~k Circuil Courl. anJ Juplw•a1r wilh Tas MawK)
BOOK~OS PAt;F~57~
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