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I)ECI.ARATIUN OF DUMICII.£ ~
To the Clerk of the Circuit Court (County Cum~t rol ler) ST •~_~~_) ~- ____ Co~~nty, Florida.
'rhis is my declarat ion of domicile in the State of t~ loTid~ ~ tt.at I am f i 1 ing
~his day in accordance and in conformity with ~ection ~~~.1'f~ Flori~da Statut~s.
F'nR DOMICII.[ARIF.S OF 'fH~ S'I'ATB OF FLORIDAs
l l 3 ~=~~ s t ~; ~ t i ~ c~:~t~
t hereby declare khat I reside in and maintain a~lace c~ ~2~+~e at •_ _ .
~~strcet <ind nu`r75er~
~ t :~t . I uci e__ _ , in ____ ST,,T~_UC 1_~~_ ~ r~~~nty, Flor±~a; which place of aboc3e I
____-_ --~~ity) - _-^«.:~ , '
:~~cognize and intend to maintain ~~s my perrn,~nent home and, if I n:aintain another ~lace or
F~laces of abode in Gome other state or states,.I h~reby declare that my above-~escribed
residence and abode in }he State of Florida constitutes my predominar~t and principal ho-~e,
~nd Y intend to continue it perrn<~nently as such. I am, at the tir..e of naking.this ~?eciara-
' ion, a bona fide resident of the State of Floric3a residinq at 1~ I'-aSt C~trlh~~can ,
• ~ ( st reet an~ nuTbet)
.~Ct 5t. I.uc:i~e , in St. I.u~ir_ C~~~nty, Flor~3a. I formerly irsided at
---____ ~c t ) ------ -----~..--------- --- ~-~-~:
:~. rii<~lci f~e~ch ~ :.r~~v,~1rd County, •`'~l.orida , and the
----_~ ---- ---- ---- -- ---- - -----_ _ --- ------ ---- -
(city) Tstate~---- --
piace or places where 1 maintain another or other place or places of abode are as fol2ows:
!iiere list street address, city, c~unty and sf.ate of any othcr piace or places of abode.)
i `3EC~~'E A RESIUENT ON T}1E 1~__ DAY pF {~C'~ObCY' ~_~ 14 .`'3~) _~
.S~se~~- -~V n?vRR ~SS~~
~N•~t: ~: o r~;:~`,.,~,~~
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f ~ ~j,; f,
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/ n ~ ~ ~) y~f • ~ ~ -_~J',. • hh'~~;. ..
~ isigr.ature ~t . ,r ,t -~t _
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,S ~-~~ L M o ~~ ~;4~ . . . . . ~ . .
:- ,~ .::~.1 "t;r~.
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":~orn to and subscribed before me this ~ day of ~?Qic-~1 ~, A%~ ~•~.~Ri;;4J• ,"~l
,. ~i ~ ., ••:,
Ro~~~ Po ~ rR~ s, c~~~tK~ c~~a~a,r cou~T
ST. l_ UC t E COUNTY, FLOR 1~(3A'''
':-~±ary Pubiic State of Fiorida at ;.arge. ~_ -~-
"y Carmission ex~ires . aY /~ -~L'~~-~~-~° GE PUT Y C l E R K
-"-~ DG!~!ICILIARIES OF STATES OTHF.R THAN THE STATE OF FLORI~A:
==-~ _:,_~ :~, ~.--~-.~.__,.._ ._,_
_ __~ y _ y State of and t~.at I ir.~end
~ .~P~'Pb dAclare that m~ vdomieile~~is in ~the~ ~~~-x~~~~~~+~~~
- o per::anently continue and maintain my 3omicile in such stare. At the ti~~e o_° *~:akir.q this
.=c:aration Z am a bona fide resident of the State of . My place of
,':,~.de within the State of Florida, if any, is as follows: iHere list st:eet address, city,
~-:3 county of place af abode in Florida.)
:~-rson making declaration :,~ay a?so include such o*_her ~nd fur*_?:er .`a~*_s «ith refer?nce ~o
--:; acts dor.e or perfor,:~ad hy such person which s~ch p~rsc,n d~s:rec or in*er.c?s not ta he
-.~~rned as evidencinq any intention to establish his dc;micile ~+ithin 'he S`ate of F2~rida.)
19~ ~IAR -5 P~ 2 i ~
~rtcc s~ ~co~a
,~.tuCtE ClJNT .E; s
RC6CR POtT~AS ~
~L[~K Ci6ttAT ~CC~'
. --- , ;,. ,-~ ~!
S19i61
(signaCure)
.: ~~rn to and subscrihed before :ne this
day of , A. D. 19 .
':~*ary Public State of Florida at Large.
~'}• Co~anission expires .
a~`~ 349 F~~~ 2fi55
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