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51~~y5
AECLl,RATION O~ DOMICILE
o the Clerk of the Circuit Court [County Coa~ptroller~ ST. L UCIE County, Florida.
~~:is is my declaration af domicile in the State of ~~O /'I u~ , that I am filing
his day in accordance and in conformity with Section 222.17, FYorida Statutes.
~~F n0!+1ICILIARIES OF THE STATE OF FLORIDA:
!:•.-reby declare that I reside in and maintain a place of abode at ?~Py SE- ~2lve~Pr~
"i ` (street and number)
f v'~ ~ 5~ L~ G~~ , 2n ST. L UC I E County, Florida, which place of abode I
(city) -
~-~ ~~.nize and intend to rr~aintain as my pern~~anent home and, if I maintain another olace or
:~~ces of abode in some other state or states, I hereby declare that my above-described~
-~=i::~nce and abode in the State of FloriBa constitutes my predominant and principa2 home,
-:c~ I intend to continue it permanently as such. I am, at the time of makin this d clara-
i~~~n, a bona fide resident of the State of Florida residinq at Z)/ ~ So~'f~ us ~~ ,
t. P~ C'r~ e' , in (street and nu:nber)
___1' _~~. LV G/ 2 County, Florida. I formerly resided at
~C h.Ju,Cvl ~~ ~''=-.~ •:
. ~/~ p~ Connty, ~~11/ /l/~ f S~ F, and the
cl y (state) -
'.ace ar places where I maintain another or other place or places of abode are as follows:
._=-:e list street address~, city, county and state of any other place or places of abode.)
'`Et:.ME A RESlDENT ON THE ~~ OAY OF ~(/~/S~~ 19 ~/ .
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__: ta and subscribed before me this ~_ day of
'~ _: ~r,- Public State of Florida at Large.
• C~-~ ission expi~es ,
, A. D. 19 ~' ~ ,
ROGER PO I A S, CL ERK C I RCU I T COURT
ST. Ll1C i E COUNTY, FLOR I Dp
B Y~.n C~~ty..~n.d~ u,Q.~~ E P U T Y C L E R K
!~~ ~~wICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
I
.°reby declare that ~ay domicile is in the State of ~1o r~ and that I intend
~- -er:..anently continue and maintain my d~micile in such state.. t the time of rr~aking this
E' Tation I am a bona fide resident of the State of _~,[ . My place of
-..e within the State o~ Florida, if any, is as follows: Here ist'sti~eet address, city,
~-. ~^~._,~~nty of place of abode in Florida. ) '
-~~n raking cieclaration may also include such other and further facts with reference to =
-: a~'_s done or performed by such person which such person desires or intends not to be -
~-..=_-::ed as evidencing any intention to establish his domicile within the'State of Florida.)
~ 5183y ; ,
1981 F~3 27 a~ i2: 30
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st.tu:::i ir:is-Y.:: .
~`G~.. ~ ,1;
CLEF:y C'='''•.- .. ~
c•--•-, ~
._ ~
(signature)
~.:,rn to and subscribed before me this
a-}• PubYic Siate of Florida at Larqe.
• c~mmission expires .
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day of , A. D. 19
Bn K349 P~~Ei451
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