HomeMy WebLinkAbout1584 ' 1 ~ +ti ^ - ~ ~ 1 t ~ i" !"1 ~ t ' t ' e~ ~,y ~
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~ro •riii: s~r,~~,~i: n~~i~ c~ov~-r~- ~r,~x nssi:stic~it, 23610'~'
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'll~is is m~~ ~Irrlaratiun of Uc~micilr ai~~ Citiicn.hip iii ih~: S~at.~ of ~lorida th:~t t ani filin~ this day in
accordanci•, and ii~ c~nlonnitv ~vith Scrtio~~ ~~'.17, ~lorida Statut~s. `
I~vas fotmCfly 1 ICr:ii nsidriit of/~~.~~~ ~ ,~•~~cQ~~' _ and I
(citr) (s~ae.)
residcd at ~~~f`'~f Ho~vcvcr, I ha~~c changcd my domicile to
(Strerl snd I~u~nbrr) ~ ~
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and am and havc Uccn , a ba~ia fidc resicicnt of ihc State of ~lorida sincc day of
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, and 1 resid~ at
! (S and NumbcY)
' ' County, T'lorida,
(citr) ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domiciie in ihe State
of Clorida.
/ (lnsert here any perlinenl facts, such as sale of property or buciness, or relinquisAment ot employmenl at formet
domieile. ~emoval ot (amify to ne~v domicilr. purchase ot home, e1c.)
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~'/?,.~%f~/''t~l~~ - #ILEO Ak^ NE p
. ~.lUC1E C4UNT~~
• ~O~En rt113J~$ N
• ~LERK C"~:~~;T CO ,y~
~ RECOR•,^ ;`arr~f0~/~ ~
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, 2~61p~
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~ 1 FURTHER CERTIrY that t~~ ill rc~istcr at my local address whrn the rrgistration books rco cn, and
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comply with all otl~er requirements oC a lc~:+l resident of this State.
I FURTIiI:R CERT1rY tl~at I I~a~~c no intcntion 1o rct~~rn to tny 1'ormcr do icilc, and I intcnd to remain in
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~ - ~ -cF~a~ . ' *,c'~ , County,
.
6~ rlorida, pcrmancnlly: (c''y~ '
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. (AdJress)
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~ S~vori~.t~~~ni~ s~ib~crihrd bcfor. mc this day of
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~ olary 1'ublic Slate uf 1 ~J~ at t_ar~:r ~
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My Commiceion rx~~irrs ` 7~ ~ -
~ (To Irr rucutrd in duplicalr ~nJ un~ia~l fdrd ~~ifh l'Ir~k ('ircuil Courl. anJ Jupla-a~r wi~h Ta• A~ccw?r)
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~a~K205 ~A~F158~
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