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5~021b
DECLARATION OF DOMICILE
:o the C2erk of the Circuit Court [County ComptrollerJ ST. L UCIE County, Florida.
:'r:is is my declaration of domicile in the State of j"[pY1~G~ C~ , that I am filinq
*_his day in accordance and in confor*nity wi£h Section f~.T~, FI-oriaa Statutes.
~OR DOMICILIARIES OF THE STATE OF FLORIAA:
I hereb~~ declare that I reside in and maintain a place of abode at ~~ ~ OX 1 3~.
, t `t street an nu er
~'r r lvl~~~ Vi ~a z', in ST. LUC 1 E County, Florida, which place of abode I
-(~c i ty -j.... r_'
r~~cognize and intend to maintain as my permanent home and, if I maintain another olace or
olsces 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 ha-ne,
snd I intend to continue it permanently as such. I am, at the time of ma.} ng this d~clara-
tion, a bona fide resident of the State of Florida residing at ~ ~ ~3-GB'1C- ~ ~ .
f~.-/-'-_ street an num r
~. {~VL(~. ~r~~ ~~~- , in ~~ ~G~X~~ County, Florida. I formerly resided at
cit ~1/t.t YI~-T ~
S , ~~~~~ County, , and the
-~-~lty ~'~K~aQ -o state
o?ace or places where I~laintain another or other place or places of abode are as follows:
~F~ere list street address, city, county and state of any other place or places of abode.)
BECAME A RESIDENT ON THE ~ ~AY OF _J~~i~~ ~ 19 D .
~~OU1Vj=y ,
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.
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c.~ ~: ~';; ~ `'y; ' c''
~ " •.~ ~''.~ _ . - .~ "~ ~
~'~~ •a ...._;~~~.ti.~_r
~~~orn to and subscribed before me this ~~
':~:ary Public State of Florida at Large.
yy Cc.-~mission expires
/ • ,
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signature
~jA~i Iiv
day of ~~.l,~ , A. D. 19 c~~ .
ROGER PO I TRFS, CLERK C IRCU I T COU~2T
~r, i i r i~ rni wrv~ F~ ~R ~ nA
B Y L~-+~ ~~G~~ D E P U T Y C L E R K
:OR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
t -:s::-~..:.:~:,:~- -~
~`iereby declare that my domicile is in the State of and t},at I intend
`o permanently continue and maintain my domicile in suc state. At the time of rnaking this
:~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: Here 2st street address, city,
~nd county of place of abode in Florida.)
•'~~rson making declaration ~ray also include such other and further facts with reference to
_:::y acts done or performed by such person which such person desires or intends not to be
~~^strued as evidencinq any intention to establish his domicile within the State of Florida.)
is~i KaR i 3 a~ ~ 43
f ILCC ~t:C ~E CON~c J
SI.LUCIF C6UN1Y,fi A.
ROGER POITRAS n
CLERK CIRCUIi CC~UR1 Li/
, .. .?i: : f • . _ . ~~- ~ - -
S;z0216
signature
:=.~orn to and subscribed before me this day of , A. D. 19
':~~ary Pu~ ic State of Florida at Large.
'f}• Cor-mission Expires _ _ _
a~350 ~a~1495