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' omicile end Citizenshi
Dectarat~on of D p
436'7`!2
TO THE CLERK OF THE CIRCUIT COURT.
L v~ t. ~ ~ COUNTY. FLORIDA:
This b my declaration of Domicils and Citiseaahip is the State of Fbrida that I am Sling this day is accordance. and in
eoaformity with Section 222.17. Fbrida Statutes.
I was formerly a legal resident of• ~ ~ Q+ - ~
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resided at ~ a ~.-ss. a c :\-sY u SAY - o
~ _ . ~ ~ ~ However. I have changed my domicile to .
and am and have been a bona fide residen8t
~
the State of Florida since _ ~ ~ ~ ~ ~ ~1' °t ~
O cfiJ b Q, r -19 ~1 g - and I reside at ~ `I ~ 1 R: ~ 4, M i ~,~1 u.
(8eewt ~sd NumD~r) 't1w a
lt~Ul
sad this statement is to be taken as my declaration of eitiuaship. actual legal residence and domicile in the State of Florida.
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I FURTHER CERTIFY that I will register at my local address when the registration hooka reopen, and comply with al!
'i other requirements of a legal resident of this State.
i
I F(~$THER CERTIFY that have no intention to return to my former domicile. and I intend to remain in
' ` ~ S c^ : L.~it,4.e. S+. L v. ~ .County.
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~ Florida. permanently.
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Sworn to and subscribed before me this ~ day of ~ .
. A.D. l9~ 436~7~7i?
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My Commission expires
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