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Declaration of Dom~cile and Citizensh~p ~
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TO THE CLERK OF THE CIRCUIT COURT.
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' Thjs is ~n~ declsration o~ Domieile and Cttiunship in t6e State ot F7orida that I am Slina this da,~ in aoooe~danes. ~ad ia
coaformit~ with Sectjon 222.17, Tloeida Statutes.
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~t ~ 5~p ~ l~ ~ ~ T~ P~- F~ ~(t~ ~ ~ V~ ~ _ However. I have changed nU domiu'le to ~
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and acn and hsve been a boaa fide resideat ot the State ci Fbrida ainee da7 °t
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and this striement is to be Wcen as m~ deeLratioa of citizenship. aetwl kgal residenee aod dom[c~e in tLe State d Flodda.
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FIIfQ AttO ktc4~ i!
' ST.LUCIF CGt~iTY. A,
ROGER POIT1tA~
CLERK CtRCtJIT CO~~~ :
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j I FtJRTHER CEBTIFY that I w~71 register st my beal address wrhen the registntion books reopea. and ccmply witb all i
' other requirements ot a kgal resident ot tbis State.
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~ I FURTAER CERTIFY that I have no intention to return to my former domic~e. and intend to remain in ~
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~ Florids. Permanentl~• ~ R,(1~? ~ E R E' R t~ D~' S` 1~ ~
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~ . Swarn to and sbbsentied befon me this ' dsy ot Sy . ~L~ ~
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' ITo be aeevted io dnpliute aad ori~ioa161ed witb C{erk Grrult Cwrt. ~ad duplieab ~itD T~ AwMOr) ~
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