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7'i) 7'1:l~: ('L!~:lt}~ U1"1'j1E ClliGUl f(;Ol~lt7'. .
?T. _LU_f, l E ~ COUNTY, F~.cittluA:
This is u~y d~~rll~ation ot 1)c~n,icitc end Citi~.cn:l~i~, in lt:c Stato ot Florida thAt I am (~ling Lf~is d:~y its aecordancc. and in
eunformity ~~ith `c•cliua :.",''...'.1?, FI~riJs Stututes.
I~?•as tnrm_ cri~ a 1~•gal msidcnt of ~1~ "~.j~ids ~ `•!ich. ~ nnd I
- IG~tyl (stute)
m•ided at P, vute 1~;;c~x 2 ,]~owevcr. I l~ave chrnged my domici!c to
(Ste'eet R.tid tvu:ntxH
and sm and havc bc•on a l~ona fidc resident of thc St~ttc ot Fbrida since 26th anY ~j
c?Cb. 1Q 78 and I reside at Qceana ~3?nf} tt
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(Street and Isumber) '
~`~~nsen ~e~;ch ST. LUG I E
~ .~Connty, Florid~,
, tCitr)
an~l this s6atrmcnt is to bc taken as my dectarhijon ~t eitizenship, acival lrgal res;dence hr,d damicile i:i thc Stat~ of Florid+,
IF F'OR YIiC i'UkPOSE OF EN~OILiNG Ii' FOR HOi~tCSYCAD pUFPQ~CSj
CHIlnf;EN IN SCHOdL~ PLEASE STAYE PLEASE CHECKS ~
THE IR NAN.ES:
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FI!_t~J Ai:J Zr~ORDED
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I FURTJiEP. CI;RTIr 1' ihat I will rngister al mp 1rMal adciress when the regi: tratioa bocks reopen. and comply wit:~ aU
oihcr requiremc•nts ~f a legal residcnl of this State. ~
1 FUItT1iF„~ CF:RTIFY that I have no inlention to return to my tormer~domicile. and 1 inicnd Lo rem:?i~~ in
- ~n t~,na,Cl . UC i f • . (:ounty. ~
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Florida, perniane~~i;,;.
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`or ~~c,~.-1~'yg•
`°~~~~'~~~f °Q `~Sartha (a/kfa Marcy) R. Root
f CGUNTY •E4
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Oceana. Apt , ~02 ~ 970Q~AlA
(Addros~)
SWorr. to: r.d s~hscrit~cd l~iore me tl?iv ~,y of Jensen Bea~h ~t. ~ac~Z ~
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RUGER_ Nnl T2l~S. C~~f:IC OF G IRf-U1 T COt~2T
ST . L E C QUNTY, F I.OR 1 UA ~
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