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~~+orn to and subscribed before me this ~
DECL.ARATION OF DOMICILE
---- •
To the Clerk of the Circuit Court [County Comptroller) ST. ~ UCIE County, Florida.
This is my declaration of domicile in the State of I~lorici~ , that I am filing
this day in accordance and in conformity with Section ., F or~ a Statutes.
FOR UOMICILIARIES OF THE STATE OF FLORIDA:
I hereby declare that I reside in and maintain a place of abode at 12 G37In~ii ar~ st. ,
street an nu er
~t~:ari , in S T, t_UCIE County, Florida, which place of ahode I
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recognize and intend to maintain as my pezznan~nt home and, if I maintain another place or
places 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 ho;ne,
and I intend to continue it permanently as such. I am, at the me of mak'r~ this dec2ara-
tion, a bana fide resident of the State of Florida residinq at ~L~3? Ln~1~n st . ~
Stua.~t street an num er
, ia County, Florida. I formerly resided at
c i ty • ~e---- ~''__ ~-,'
~'avanr.ah , Chatham County, ^~~r9ia - , and the
city state
place or places where I maintain 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.)
t3ECRt+.E A RESIDENT ON THE 1G OAY OF R~C~ ~ 19~~.
/
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signa ure
S~AS21
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~ ~tNllititit~~t~
,~~,a.,a G - y~,~-~~~-y, ,.
.,
~ ~~~,}~ano~ 7;~~ f'4,
day of (, , ~:~;l;~,••f19~ :~: ~'..
. , , ~ - ~ . : . ~: ; -': .
ROGER PO I TRk S~~~~K c ~.~c~i~''~~'.~O1~2 T
ST. UC 1 E COU~~.~ ~.~OR~ ~A°~ s` -
`:o:.ary Public State of Florida at Large. ,sc~ : ;t;~ - ~ :',~ '
*"y Co.zunission expires BY '- ~' _ b~E~~t~'Y GIERK
• f ~ '-.,,• - ~:~'. ~y
:OR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FL ID : ~~~i~~e ~~'~t~`.``'~~~,`
~~..,~ ..:
...~..~~~~... .
~ - _ -.~~ ~~.,~,....a~;rr~r~.sr3s~e~e~ -
: ae~~by declare that my domicile is in the State of and that I intend
to penr~anently continue and maintain my domicile in suc state. At the time of ~:aking this
~eclaration I am a bona fide resident of the State of My place of
-::,ode within the State of Florida, if any, is as follo~as: Here ist street address, city,
and county of place of abode in Flarida.)
'~Arson rnaking declaration r~ay also include such other and fur*_her facts with reference to
::,y acts done or performed by such person which such person desires or intends not to be
~--:strued as evidencing any intention to establish his do:nicile within the State of Florida.)
s;~osz1
1981 NAR 16 P!i 3 29
in~o ~ao 4: ccR cr.
st.~ucir ccu~ir~f~ a.
naG~R roizRas
CIERK CtRCUST Cf lJ i~
PE~^Ff' :'! ~'4 '~ '~ ~
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signature
'~«orn to and subscribed before me this day of
':~tary Pub ic State o Florida at Large.
~'y Comtr:ission expires
, A. D. 19 .
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