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Declaration of Domicile and Citizen~h~p
46~0~8~~
TO THE CLERK OF THE CIRCUIT COURT.
l•IC I ~ COUNTY. FLORIDA: .
This is trey decLratbn of Domicils and Citisenship in the State of Florida that I am Sling this day in accordance. and is
conformity with Section 222.1?.1:7orida Statutes.
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I aaa formerly a legal resident of ~ / ~ ~D /U D / l~ and I
resided at 7 ~3 ~ ~~-/r1"~~' / ~/f~ ~~/9 _ However. I havsehanged ~ domia7s to
(Stmt asd Numbee) ~ t/ ~
and am and have been a bona Sde resident of the State od FbrWa since
~ G- /Q .19-~ l . and I reside at ~J~~ / ~~~/•'9
s lltraat asd Nm~bar) -
~zG ~ LffCi~~ County. Florida.
and this statement is to be tale>>en as tqy declaration of eitisenship, actual bgal residence and domicile in the State of 1.7orida.
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t9~ MAR 26 AM 9~ 53
f ~ Y. A.
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I FURTHER CER1`>FY that I wt71 register at my local address when the registration books reopen, a~ oomph with all
other requirements ~ a legal resident of this State. _ ,
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- I FURTHER CERTIFY that I have no intention to return to my former domia7e. and I intcnd to remain in
e~ t- ,riE . L ucl~= s~ ~ u f ,County,
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Fbrida, permanently.
F
i
Mama
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" ~ ~ ~i~t j before me this day ~ orj > ~ ~f u~ ~ /1t _ ~1 y 5
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~ A.D.19 ~D C ~JJ ~
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. a? iL..-1 sue-.-
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Btsta d Fleeids at I~
M ~'F[Q,'~t"w~'~'- 02.3 g ~ -
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ITo be a:eeuted in dupliutR and orisind bbd with Clerk Circuit Court. and duplicate witl+ Ta: Aaeeaeer)
B~~ PatoG ~ Afn Form 71 ~?2
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