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Declaration of Domicile and Citizenship
Sa.n.3'7'7
TO THE CLERK OF THE CIRCUIT COURT.
~~ _ ~ `'~ c / £ COUNTY. FLORIDA:
This is m~ declaration of Domidb and Cltisenship in the State of Fbrida that I am Sliaa this dad in accordance. and in
oonformit~ with Section 222.17. Fbrida Statutes.
I wss formerly a bgal resident of ~A ~ ~- E Y .~T~~ A M /U- y and I
~at>> -~s~r.~
resided at 1 ~ 7 ~A'Q~F'y~ ~E _However. I have ebaciged m~ domia7e to
~:w..t..arrme.r, ~,
and am and have been a bona Sde resident of the State of Florida since S- dal ai
/yo alt ~.~ ~ K ,19 0 ~ . and I reside at ~ o "r / 3 33 '~rF Z /~2 TT« /' .._ti~/9~~
(lltrNt NmD~d
aJ rN J E~ ~i_= AC i/ r r _ ~ ti C i ~ Camt~. Florida.
1Ct41
and this statement is to be ta)<en as m7 declaration of dtisenship, actual bgal residence and domia'le in the State d Florida.
1960 OEC 12 PN 2 07
fIlEO ANC pCCORI1tD
SL~IlCI CQUNtY.FLA
CLE~~C RCUIT OURt
RfCCR01'F~tF;i'~_ _ ~~~ 4
I FARTHER CERTIFY-that-i w~71 register~t- mY bed when-tbcre2estntion~oob reopen, and ooa~j with aD
other requirements at a bBd resided o[ this State.
I F'UR1'HER CERTIFY ~wi~7~~~I have no intention to return to mr tocmer domicile. and I intend to remain is
~C~~~ _
Fbnda. permanently.
~ ~. 9 ~~
.: ~ :,~y..~ r
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d before me this ____~ day of
A.D.19 ~~_
8taadPloeidaetI~
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iKy Commission espires ~ " IC STATE u. r~~t~a- Al Wc+~
M. COlruruSSi01+ Exf~tES NIAR. tt I~iN
WtrOt~ +-BU GfNERAI DNS t1NDERWYT~
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(To be e:eeut~d m daptieate aed oriRiwl /ad +W Ciwk Qrart Cant, aid ~timte wlta Tas AaMrotl
AGO Form 7l-?2