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Deciar~tion of Domicile and Citizenship
~ro Tii~~ sTn : nNU covh~~~~ ~~~x assi:s~ok. 243219
. _ ('OUNTY, (~LORIUA:
Thi~ i. my~ d~claratiun ol Uomicil~ an~l CitizrnshiE~ in thc Stat~ of Florida that t am fiting this day in
.irronlancr, an~1 in ronlormity with S~rtion ,,,.17. Florida Statutes.
i was fonncrly ~ Ir~;;il rrsid~nt ot~ NOr~~-~~ - - - - - . _ - --S~t~rl~icU.~'_ and 1
(crtY) (s~e~e~
rrsidrd .it 3 3 --~UQ~n u+ ~.n f~~ . How~ver, 1 have changed my domicile to
(Strrrt and Numbar)
and atn and havr br~ n a hona ii~t~ rrsidrnt of the State of Florida since day of
~~ece,rn~er 1~) anii ( resid~ at 5~ 5._~., _ ~,liP_
- - - . 3 _ -
(~trrrt and Number)
~Qr-~ S~-. _ LU~y . - _ - . County, Florida,
_ - ~c•~~. ?
:~nd ti~is statemc:nt is to br tal:rn at my de~laration ot~ ~itirensliip, artual legal r~sidence and domicile in the State
of' Florida.
(Insrn hrrr any prrl~nrnt f~cts, ~u~h s~ sal~ of p~uprrty or Ausinrss, ur telinyuishmrnt of employmrnt at formrr
domicile, rrmu~al uf famih~ to nr~~' Jumicil~, purch•sst of homr. rtc.)
SU 5a n t~ e
e -F~r e y
~t~le r -
FtLEO Ahr 4,C~RDED ~ ~J~:~
ST. LUCti ~~)UHTY FLA. ~t
RaCEit ?~tTRAS
~~ER~ ::`:~:::iT COURT V
RECC~!` :^f'::tQ
D~c 6 li ~s pM'11
243219
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; 1 FURTHER CERT[FY that I~ti~i1( rcgist~r at my local addr~ss wh~n the registration books reopen, and
~ ~omply with a!I other requirem~nt~ e~f a le~*al r~sident c~t~ this $tate.
~
` 1 FURTHER Cf:RT1FY that 1 ha~~r intcnti«n to r~turn to my forn~er domic-ile, and 1 intend to remain in
I
i ~__~Q~~- . I,~vc~ _ Coun~~,
- - _ _ _ - -
Floridek {~t~r~Jt~yntly ~c:~•?
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n 'i,~' '
'`,~"(i~,~, _ ~ILS~i~__.~~_~'~Z_~1"-- 4
~ ~ ~ _ (Name) '
o~~,~~"~;~` : U . }
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_ ~ ~t ; c,~aa~~u~
- •
; Sworn;.to;;en~`subscribrd brt~~rr me this ~fay of
;
~--C-~ _ A.U. 19~ .
- ~ - ~1 _ - - t
~ Nuta Public State ~rf FIur~Ja at Latk~{ , - :
! " \J ~ ~ {
l~iy Commission rxrires . ~ _ I ~v ' t
~
(Tu br rcrcutrJ m Jupl~catr and nn~inal fihd ~~ith ('IerA ('ircuit C~~urt. anJ duplicatr with Tax Assessor) ~
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