HomeMy WebLinkAbout0983 1, f F1e ) - ~1 t 7~._._ ~ ?~7 ~C O W.S 1~ t
~ (plcase print your name clc~rlyj
became a bona fide msident af thc State of Florida on ~ U~, , I'-i 19 b 3'
and I reside at > ~ ~~5~ ~ ' L ~ _
in the Cit7l ~ o T ~ t K C~ ~ y
My mailing addmss is;
(if differ~ent from sti-cet addness)
My former lcg~31 ziesidenoe wa.s in the City o~ _ - ~ ~ j~_
sc~ce ~ N c?~ ~ E ~z Y
~
( No fiuther statement is requizsd. Nowever, if you wish, you may
insert any pertinent facts such as salc of pxnperty or business
or relinqui.shment nf employment at former domicile, ziemoval of
family to new domi~ile, pur~hase of home, etc. )
I FURTHER CERTIPY I will oorriply wiih all rt~quincincnts ~f
a legal msident of this St~te. I undcr~~l.and thc:-~ is a penalty
for perjury; perjucy is a Fe1Lx~y and is puni~:h~~bl~ by incar~,tian
in the State Departmcnt of Coz-n..~tions.
{ ( ~ ' ~ a~ ~ ~ t.,' ~ ~ r~ .,.«.1 t ~ • ~c-.
~ PRINT ~ AME SIG ATURE
i -
E
; ~ _ ' '
; i'[tINT rY11ME SIGNA'!'UKE
(
; Sworn to and subscribed before me thi, ~day o8,~ 19
~ - ~
~ DOUGL DIXON, CL RK IRCUl~T CO ~
' B - ~,h~~? 'Nr~C~
F r C~ 0 9,pS79~
~ ~ Ocputy Cl~rk r ~
Ci Jt ' ~ C!!
~4~>-'~:;aT ?b ~2 ~26
, . .88 ~
r a . •~~Xii.
NOTARY PUBLIC, STATE uf ~
F,_f ~ : ; . . r ~ ~ ~ ~
MY COMMISSION EXPIRES: OQ~ju! ;
~ $S. l.U~ .
~
r
4
s
s
aooK 596 983
~
~
. ~ . y
~ ' ~s"~'° - _ _ -'"wx'. v. 'a' `
°
. ~ .
~
~
~
~
~
~
~