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DECLARATION OF DOMICILE
To the Clerk of the Circuit Couzt [County Comptroller~ ST. L UCIE County, Florida.
This is my declaration of domicile in the State of , that I am filinq
this day in accordance and in conformity with Section Z~'F.Ti, Flori~a 3`tatutes.
FOR DOMICILIARIES OF THE STATE OF FLORIDA:
T herPhv r~a~t A.-P ±ha~ ;~Q~_a~ ir. ~r.3 ,..aintain a~Iac;e o£ aboc3e atC~~~~~! 1'~tf ~ l ~
l'street an n er ) ~
j~~ S~~ ~~~!GJ~. , in ST. LUC 1~ County, Florida, which place of abode I
(city f `_'~
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 home,
and I intend to continue it permanently as such. I am, at9the time o~ ki~h~s ~ara-
tion, a bona~fide resident of the State of Florida residin at ~~2 S/ S
-~ ~, street an number)
r'%;,Zj Sl y-UC/~,' , in ~`(~~/~ County, Florida. I formerly resided at
~ (city) ~
, County, , and the
~city~ (state)
place or places where I maintain another or other place or places of abode are as follows:
(Iiere list street address, city, county and state of any other place or places of abode.)
i BECAME A RES 1 DENT ON THE r~~ DAY Of ~~~ t't , 19 7~'='.
,~~ ~ouNry
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Sworn to and subscribed before me this ~~
Notary Public State of Floric~a at Large.
~L
/~
~
day of-~.~X~c,~ , A. D. 19 Q~.
ROGER PO I 1RP S, CL ERK C I RCU I T COURT
ST. tUCIE COUNTY, FLORIDA
:~y Commission expires . B Y~ ~~°-' OE P U T Y C L E R K
~~
FOR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA: .
1 ere y ec are t at my omicile is in the State of and that I intend
to permanently continue and maintain my domfcile 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 Florida.)
(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 evidencinq any intention to establish his damicile within the State of Plorida.)
1981 FE~ 23 A:~! il~ 29
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51'~'714
(signature)
Sworn to.and subscribed before me this
, A. D. 19 .
day of
*lotary Public State of Florida at Large.
~y Commission expires .
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s~ 349 ~~~ 243
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