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, T6ts ia my decia~ation of Domicitc and Ltitiunshi~? in t6e Siate o! F7orida tbst I am G4ns this day in accordsnee. aAd ia
eontormity w~icA sectia, r1z.17, F~wida Staeutes.
~ I was tormcrtv a IeRal reaideat ot , ~ and I •
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teside~d at Y ~ 4 No~rerer. I 6ave changrd mr domieJc to
tSt+e+t ~d Nroeler) ' I
aad am and hare bec n a boaa fide resideat ot thc State oI Flotida sinec /~,2~~'~ day of ~
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.and this stateaaent is ta be Wcca as my decLntion ot titizensbip, sctual kgal resideaa and domic~ in the State d Florida. -
• IF P~R TIiE PURPOSE OP EPlROLLtNG IP POR HONEST[AD PURPOS[S~
C111lDREN 1 N SG?IOOL~ PLEASE StATE PLEASE CHECK: rf~-
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fILEO ~lltt ~iEC~R~E~
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~ CIEitiK ~?r.~1f1? COURT
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• I FURTlIER CEHTIFY lhat I w~! re~stcr at my io:ii address ~rhen tbe regisiralion books reopen, and complY with aU
•oti?cr requirements of a Icga1 resident o! ihis State.
I FUR iE;t .RTIFY ~hal I~h v iw int~nt' to mturn b mr former domic~lc, nnd I intcnd W rcmain in
- J2~''~ -~r S7 . 1_ ut 1 E , Couaty.
1(St71 .
F)orida. permanenti; . •
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Sworn to and subxriLcY1 bcforn mc lAis , day of ~
l A.D. lg i
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~ ROGER F'0lTRAS_,_CLERK OF GIRCUIT Ol~2T ' j
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