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' il~ Jx CLARATION OF DOMICILE
To the Clerk of the Circuit Court [County Comptroller] ST. L UCIE County, Florida.
This is my declaration of domicile in the State of that I am filing
this day in accordance and in conformity with Section , F on a Statutes.
FOR D~MICILIARIES OF THE STATE OF FLORIDA:
I hereby declare that I reside in and maintain a place of abode at 104 W. prima Vista ,
street an n er
Pt St . Lucie in ST. LUG I E County, Florida, which place of abode I
city
recognize and intend to maintain as my permanent home and, if I maintain another place'or
places of abode in some other state or states, I hereby declare that my above-described
residence and abode in the State of Florida constitutes my predominant and principal hone, -
and I intend to continue it permanently as such. I am, at the time of making this declara-
tion, a bona fide resident of the State of Florida residing at 104 yy. prima V ist . ;
street an n r
Pt . St . Lucie ~ in St . Lucie County, Florida. Z formerly resided at .
city
DE Pere - Brown County, Wis~o and the
city state -
place or places where I maintain another or other place or places of abode are as follows:
(Here 13st street address, city, county and state of any other place or places of abode.)
None
I have resided in Florida. since January 1979.
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- . ~ t c,;I signature
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_
Sworn td~;~ii~;ubscribed before me this ~ day of ~~~l~j
A. D. 19~.
_ ROGER PO I T12a S, CLERK G I RGU I T COiIt2 i
ST. LUGIE UNTY, FLORIDA
P.otary Public State o Florida at Large.
My Commission expires BY DEPUTY CLERK
i
I FOR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
r -
I ereby declare t at my domicile is in the State of and that I intend
f to permanently continue and maintain my domicile in suc state. At the time of making this
declaration I am a bona fide resident of the State of My place of
f abode within the State of Florida, if any, is as follows: Here ist street address, city,
k and county of place of abode in Florida.)
6 (Person making declaration may also include such other and further facts with reference to
any acts done or performed by such person which such person desires or intends not to be
construed as evidencing any intention to establish his domicile within the State of Florida.)
4~ifi008 -
1980 NA'i -8 PM 4~ 02
F Ep I~NO PEGppLEO
S ROGIER
~OITMSA.
q.ERK CIRCUIT~~
I
R{¢d>4G ~CF.IF:f
~ ~ signature
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f Sworn to and subscribed before me this day o~f , A. D. 19
~:otary Pub is State of Flori a at Large.
~'y Commission expires `
~
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