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51916t3
DECI.ARATION OF DOMICILE
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To the Clerk of the Circuit Court [County Comptroller) _ ST, l_UCIE _^ County, Florida.
;his is my declaration of domicile in the State af ~~~~'~ , that I am filing
this day in accordance and in conformity,with Section ~. , FI-oric~a Statutes.
'r'OR D0~11CILIARIES OF THF. STATE OF FLORIDA:
I hereby declare that I reside in and rnaintain a place of abode at c3~~~ ~c~%~ b T ,
(street ana nurr~er~-
~2T~E'1~~ . in .___ ST`_l_UC te _ County, Florida, which place of abode I
~city~V^- --- ---- .r.... f ~
;~~~oynize and intend to,maint~in as my permanent home and, if I maintain another place or
;laces uf abode in so:~e other state or states, I hereby declare that my above-described
:esidence and abode in the State of Florida constitutes my predominant and principal hor.ie,
~nd I intend to continue it perm~ner.tly as such. 2 am, at the time of r king t~,ris declara-
! ion, a bona fide resicient of ti~e 5tate of Florida residing at ~~ T~_ ~'~'t- ,
-~ stree~ n~ nur~t~er)
~yOQ,T ~Ci2C`c~ __, in ~: _; _~f C~c_' County, Florida. I formerly resided at
i t ) . _.-,_
city ' '~~ T~ ~-------- CountY. ~~C~Tt _~yi~/~/J , and the
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place or places where I~maintain another or other place or places of abode are as follows:
(Nere list street addr~ss, city, county and state of any other place or places of abode.)
I QECAME A RESIOENT ON THE ~i.7 ` OAY OF ~~( ~ 19~I .
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~ (signat rel~~~
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~worn to and subscribed before me this S day of
':~tary Public State of Florida at Large.
My Co,-„mission expires .
DEPUTY CLERK
=0R DO!9ICILIARIES OF STATES OTHER THAI3 TFiE STATE OF FLORIDA:
~ ~:.~,~~: .as~, ~--~..~.-.~- .u..~_~..:.~w~..f-~,:~-:~.~~:~.~~:~-::::~t~.~s~~a-~ ~
i~ereby declare tnat my domicile is in the State of and t~.at I intend
~o per~ranently continue and maintain my domicile in s ch state. A± the ti:ne of ~aking t~is
ceclaration Z am a bona fide resident of the State of . My place of
-sbode witT.in the State of Florida, if any, is as follows: (Here list street address, city,
~nd county of place of abode in Florida.) ~
!?erson r.:aking declaration may also include such other and further fac*s with re`erence to
~ny acts done or perfor;*.ed by such person whicts such person desires or ir.tends r.ot to be
-:~strued as evidencing any~intention to establish his domicile within the State of Fl~~rida.)
. 519168
I~1 MAR -5 ~ PH 2 I g
FI~EO ~NC Ff~Ontli t1
ST. UCif COUNtY.ii IY.
R~GER PCI i R~ S
CLERK CIflCUf1 COIiRT ~
~~i i 1~~~.~~~ 1: ~: j ~7 ~(
~~ c
(signature)
..~•~rri ~to and subscribed before me this day of
':~tary Public State of Florida at Large.
~'•y Co:n^:ission expires .
~
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_ , A. D. 19~.
ROGER PO I TRt~ S, CL ERK C I RCU I T COU~2 T
ST. LUC i E COUNTY, Fl_OR I DA
aY
, A, D, 19
~~'~ 3~9 P~~~~~6fi
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