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7't1 TI lN: CI.EIiK Ol~ TIiF: CII~CUIT COUIZT.
ST . L UG 1~ CottN7'Y. FLOR1Un:
Thi~ is my dcclaration of Domicila and Citir.~nship in tlie State ot Flurida lhal I sm filing thia dny in accordance. and in
cuntorn~ity with Scctiun ~22.1T. 1~'lorida Stnlulce:
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I w as [ormcrl r le~al reyident o( ~ (State)
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residecl nl C~ ~e G, r~ .~io~•evor~ I havo chan~d my domicile to
(Streot u~d Number)
~ o~-~ dsy of
nnd rm nnd have bcen a bona fido resident ot the State ot Florida aince
. • ~ cJ t
.19 ~
~ . and I reside nt ~ ~ r • ~ ~ _
- (Strnet and Ilumbcrl
ST . L lIG I C County. Flo:ida, '
(Cn~) - • ~ 3
and this slatement is to bo taken as my decla?•atcon of citixenship. actual legnl residcace end domicile in the SLal.c of Florida. '
IF FOR TNE PUkPUSE 0~' EItROIIlNG If FOR HOMEStEAD PURPOSES~
CHIL~RCN IN SCNOOL~ PIEASE ST/?TE PLEASE CHECKt ~
TttE1R NANES:
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r~~=~ ;.~l~ R~CORDED'
c' ~LtCic CrU":TY FLA.
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~ C~ERK ~irc~~1~T i,C'JRT ;
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~ I FURTIII:R CEI{TIFY lhat I will rc~.rist.er at, my local yd~ress N•hen tt:e re~istration books rcopen. and com~ly ~vit1? ull ~
i o.hrr requirements of a legal resident ot ihis State.
~ 'Z CFI~TIFl th::L 1 havr no inL~•~ti~~r+ to r~turn t~~ rny forrn~r dns-+.~~ilc, and I intcr.d
to~
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i FURTIIF:.
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