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DECLARATION OF DOMICILE
'ro the Clerk of the Circuit Court [County Comptroller] ST. Ll1C1E County, Florida.
Th~is is my declaration of domicile in the State of , that I am filing
this day in accordance and in conformity with Section z~~1.'3, Florida statutes.
FOR DOMICILIARIES OF THE STATE OF FLORIDA:
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I hereby declare that I reside in and maintain a place of abode at q~y / le. ,
' ~~stree an n erj
~~_ , in $T,~.~ 1~ County, Floridn, which place of abode I
Ccity)
recoqnize and intend to maintain as my pezma,nent home and, if I maintain another place or
places of abode in some other state or states, I hereby declare that my above-described
residence and atS~ttL'in the State of Florida constitutes my predominant and principal home,
and I intend to continue it permanently as such. I am, at the t' e of cinq thi dg clara-
tion a bona fide resident of the State of Florida residinq at ~l~• ,
. ~ . street an numberj
, in ~,,,wl.t{._ County, Florida. I formerly resided at
, • , c ty) • ~
~(J , County, , and the
city state
place ar places where I maintain another or other place ar places of abode are as follows:
(Here list street address, city, county and state of any other place or places of abode.)
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BEtAME A RES I DENT ON THE ~_ ~AY OF ~~• ~ 19~L.
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Sworn to and subscribed before me this a~ day of ~~~G~f.u~, ~ A. D. 19 g~ .
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ROGER PO I TRp S, CLERK C 1 RCU I T COU2T
ST. LUCIE COUNTY, FLOR{DA
`7otary Public State o~ Flori~a at Large. ~ /
My Commission expires . BY ~,~w~., DEPUTY CLERK
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FOR AOMICILZARI$S OF STATES OTHER THAN THE STATE OF FLORIDiA:
I ere y eclare t at my omicile is in the State of and that I intend
to permanently continue and maintain my domicile in such state. At the time of making this
declaration I am a bona fide resident of the State of My place of
abode within the State of Florida, if any, is as follows: (Here list street address, city,
and county of place of abode in F2orida.) .
(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.)
196! FE~ 23 ~!~ .~ 10
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sworn to and subscribed before me thfs
r~otary Public State of Florida at Large.
'~y Commission expires .
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f~~GER P01 i R ::
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(signature) ,
day of , a. D. 19 .
~~~K 3~9 Qa~E 165 -
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