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Declaration ~f Dornicile and Citizenship t
32J$~.3
TO THE CLERK OF THE CIRCUIT COURT. ~
S~ . L~2; ~ covrrrx. ~.o~une: -
This is my deelantion of Domicile and Citirenship in ths 8tate ot Florids thst I am Hlins tAis da~ in aaooTdanoe. and in ~
conforaaity with 3ection 222.17. FbtK:a 3tatut~.
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I wss foncerly a legal resident oi ~ 1 V~ ~ P y~ ~t ~r- S ,
((~t~l tet~wl
resided at ~ e e~ . However. I 6sve ehanged nq domicile to
tsw.e.va xossr~ t~ ~
and am aad bave been s boaa 6de re~ident oi tbe State ot Fbrlda sinoe ~7 ~
~uA ~ St .19 ~6 - and I reside at L-~S ~ ~o ~ ~ ~ ~ Q ~ OG~C ~ ~ O . 1'O r"'f '
(Stiwt nd NmbKl -
S~'. Luc,.~ Sec:~tw? .3 , S+- L~~cc,~- c«~nh?,~a..
tc~v~ .
and this statemeat is to be taken as m~r declantioa ot eitiunship. ~ctual legal residenoe and do~ieile in the 3tate ai Florids.
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I FURTI~A CEBTIF'Y t6at I vrn71 register at m~ loeal addnsa when Lhe registntioa booka reopen. and oomply with all
other requirementa of a legal e~esident of thia Stata. :
I FURTI~R ~ERTIFY that I have ao intention to retnrn to my former damicibe. and I intead to remain in
~'o 1'f~ L uc, ~ S~ . L u c t ~c.. , Councy.
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~ Florida. permanently. ~
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! Swom to and subxn'bed before me this ~'ti' day of ~'u~~ ~~a ~~~`~3 ~
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f s., s~' ,~0~~`~``ITo be ~ecuted in dupliate aad orisind 61ed wit6 Ckrk (xe+euit CwR. aod dup&ate wit6 Ta~c As~swar)
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AGO Form 71-22
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