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DECLARATION OF DOMICILE
(WE ARE NOT ATTORNEYS AND CANNOT ANSWER YOUR LEGAL QUESTIONS)
(After completion take this form to 201K,•ot the end of tho corridor).
? Check here If you are a married man and wish this declaration to include your wife.
This is my Declaration of Domicile in the State of Florida that I am filing this day in aaordance and
in conformity with Section 222.17, Florida Statutes.
I, WALTER EB>li!IQR
(plwa~ print onb YOUR noa~) ~
become a bona fide resident of the State of Florida on ...October.l6,...1978.. .
coa?. d arrlvo4
and I reside at . - 112 -East- Altiea_ Street
(Str.p 1t house nva~ba)
in the City of Port. St...Lucie,
................St-,--Lucie.-Co~ttY.,..............Flo!r3da_33452
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My former legal residence was in the City of..1305,Richland Botilevard,...Bay..St~re, Long Island,
S*cte of Nit .Xc~xk
pro further statement is required. However. li you wlsh. you may insert say pertinent facts such u sale of prop.
erty or business or relinquishment of employment at former domicile. removal of family to new domidle. purchase
of home, etc.!
~tLEC ~i; ~ RECORDED
9~9l3
'79 A?~ 27 AM 10: 43
- I FURTHER CERTIFY I will comply with all requirements of a legal resident of this State. 1 understand
i
ripe penalty for perjury is up to 20 years in State Prison - (Section 837.01, Florida Statutes).
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(Your slpnoturo~~~.
112. F~asz..Alma.Stxeet
tYa+r nollirp addrwj
I
Port..St_.-Tru~i p,..Florida..52
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iPLEASE ENTER THE DATE BELOW AND TAKE THIS FORM TO 201-K AT END OF CORRIDOR TO RECORD.)
Sworn to and subscribed before me this .~.-.~vv~ day of ........C~?.J A. D., 19.~~.
s -
JOHN B. DUNKL erT k Circuit Court
~ PALM BEAC UNTY, FLORIDA
LVtT OOG
STATE
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FLORIDA - ~ •.•.1~. D. C. 3
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~ ~~~iE AMY OMMISSION EX ORES AUG~30;T1' 00 Q
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