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519312
DECI.ARATION OF DOMICILE
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To the Clerk of the Circuit Court (County Comptrollerj $T. L UCIE County, Florida.
This is my dec3aration of domicile in the State of :~~;~~"~~'~, , that I am filinq
chis day in accordance and in conformity with Section 22f~'f;- Floric~a Statutes.
i'OR DOMICILIARIES OF 7'HE STATE QF FLORTDA:
I hereby declare that I reside in and maintain a place of abode at I~~".' '' ;~ 1!? ~,trc~et ,
.~ ~.:. :'? c~rc c , in (street and number)
_ ST. l UC I F Count}t, Florida, which place of abode I
(city) ~,,, r
recognize and intend to maintain as my perrnanent hcme and, if I rnaintain another nlace or
places of abode in some other state or states, I hereby dec2are that my above-described
residence and abode in the State of Florida constitutes my predominant and principal horne,
and I intend to continue it pez-manently as such. I am, at the t~,of making this declara-
tion, a bona fide resident of the State of Florida residing at '' 3~:L1~ "'t ,
(street and number)
; t. '? c~~ :.<~ ~ ln ~~t . I,itci c- County, Florida. I formerly resided at
( c i ty ~ ~.:.-------;..
,>1 -... _':; ~.1. ~ - • '':; . -•-_ 'r~• - ' t:, r': County ~'-..~-_..'_a ~ and the
(city) • istatel ~
alace or places where I r.^,aintain 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.)
I BECRN.E A RESIDENT ON THE •- DAY Oi'
~~a GOU!Vr~~,'7
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3:~ . _ ~.:~ 19 -.
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(signature)
S~+orn to and subscribed before me this lo a
':~~ar}~ Pvblic St~te of FZorida at Large.
~'y ConuTission exnires .
day of '~/~~tl'~ , A. D. 19 ~~ .
ROGER FO 1 TR~ S, CL ERK C I RCU I T COU-2 T
ST. LtK I E COUNTY, FLOR t DA
B Y ~~~ ij ~2~'~''-~-c.'l-- D E P U T Y C l E R K
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=~~R DO!rlICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
• . : 3:~~s. ~^aa,.~z..~ z -:~_-~a:~ :.=s:~.r~%:~s.~~.°. Y• - 4~s.°it~z.s""-.s.~.: _.<_c_t~"~-'.--AL +'o~"L:E'.: --'~r~
.:ereby declare that my domicile is in the State of and that I intend
*_o perr:anently continue and maintain my domicile in such state. At the time of .~aking ±*:is
?~~claration I am a bona fide resident of the State of . My place of
:~-~ode within the State of Florida, if any, is as follows: lNere list street address, city,
:nd county of place of abode in Florida.)
;?erson making dec~iaration may also include such other s~d fvrther facts with reference to
::y acts done or perforr~ed by such person which such pers~n desires or intends not to be
_~.nstrued as evidencing any intention to establish h~s domicile within the State of Florida.)
~a~ NaR -s ~.~ ri~ oT
FiLEO Rh~ ~rCOF.tltO
51~CGER i'OItR^ SA /1
CLE~+K ~~RCUIT C.,L'R,, i
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519312
(signature)
'~worn to and subscribed before me this
day of , A. D. 19 .
':otary Public State of Florida at Large.
'~`.y Com.,ission expires .
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