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51~845
QECLARATION OF DOMICILE
To the Clerk of the Circuit Court (County Comptrollerj ST. L UCIE County, Flurida.
This is my declaration of domicile in the State of F L U rL /~ , that I am filinq
this day in accordance and in conformity with Section 772. , F orida Statutes.
FOR UOMICILIARIES OF THE STATE OF FLORIDA:
I hereby declare that I reside in and maintain a place of abode at .Z fOd /, ~l'~AN~Z¢iv~
. istreet ancl number)
F~~7` ~l~y7CC , in ST. LUC I E County, Florida, which place of abode I
(city)
recognize and intend to maintain as my penmanent 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, at the time of making this declara-
tion, a bona fide resident of the State of Florida residing at a~In v$.~' ~i~.tJ ~dll~~
(street and number)
/~~7" ~~GP~ cP , in ~~ ,~~ County, Florida. I formerly resided at
(city) ~nd the
E -. /19~ R/1/M,/¢ C~ County, ..f'
city state '~
place or places ~e e I~m~ ntain another or other place or places of abode are as follows:
{Here list street address, city, county and state of any other place or places of abode.)
~
BECAME A RESI~ENT ON THE ~s OAY OF /2 19 ~/ .
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ig ature s' • y~, ~ ~ ' • ~
~l~E~c ?l !`n _ U%~' ~ ~ .c:f.~ °}~•_-Y~.'~-f ~•,.
, ~.~- . , ~ ~„~j.t' :
~~ day of ~ P~ , A. D ~~ ..~. ~ .~ :
Sworn to and subscribed before me this ~~~•„t,,~'''-:
,•.
ROGER PO I TRA S, CL ERK G I RCU I T COUR T
ST. LUC I E COUNTY, F,COR I DA
~yotary Public State of F].orida at Large.
My Commission expires . ~- ~~~~< «'~'~ DEPUTY CLERK
~ / ~
FOR I20MICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
ere y dec are t at my omicile is in the State of and that I intend
~o permanently continue and maintain my domicile in sucri 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 evidencir-g any intention to establish his do~nicile within the State of Faorida.)
S1'7845
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Sworn to and subscribed before me this
r+otary Purilic State of Florida at Large.
"~y Commission expires •
(signature)
day of , A. D. 19
a~`rn~349 r~cE 537
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