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DECLARATION OF DOMICILE
~~
.
To the Clerk of the Circuit Court (County Canptroller) ST. Ll1G1E County, Florida.
This is my declaration of domicile in the State of ~~0 ~R a. , that I am filing
this day in accordance and ia conformity With Section z~~.TT, ~foi~d'a ~tatutes.
FOR DOMICI7.I1-RIES OF THS STATB OF FLORIDl1:
1 hereby declare that I reside in and maintain a~ place of abode at a!o 0 I.oRA~ ~~/p, ~
f1 ~'s'treet anc~ nunueerf
tT. ~r'I e~ C e , it- ST. Ll1C I E County, Florida, wAich p2ace ot abode I
(cityl
recoqnize and intend.to maintain as my per`manent home and, if I maintain another place or
places of aDode in son-e other state or states, I hereby declare that my above-described
residence and abode in the State of Florida constitutes my predomfnant and principal haae,
and I intend to continue it permanently as such. I am, at the tfine of makfnq this declara-
tion, a bona fide resident of the State of Florida residinq at oZlo O C ,
/~ (street an n r~
Fi"• V~ieQc e , in S% • L uCi e County, Florida. I fonnerly ,resided at
(city) ~~
ti` 1 r2' g iN/ G~ , ~HS7y~ ~~P County, ~/i ~~i i N~ ~ , and the
(city~ (state) -
place or places where i maintain another or other place or places of abode are as follows:
(Here Ifst street address, city, county and state of arty other place er places of abode.)
. ~
fr ClfFr - •• ^ ~
J~~~COUNTV
Q~' ~~~i~~• ` 7C7 ~
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!."': _' .i~:: `,n
~~ ; '~=- "`•- oQ C siqnature y
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~~ r"'''~-~' {J/4v~ d Le~ ~ Y~9 N S -
Sworn to and subscribed before me this ~ clay of ~~~~~ ,~. D. 19 g~ .
ROGER P41 TRA S, GL ERK C 1 RCU i T COUR T
ST. Ll1C I E COUNTY, FLOR I Dp
Notary Public State o~ FYorida nt Larqe. ~ (~,~1 ~A
My Commission expires . Btr T'6~-G~ OE P U T tr G L E R K
FOR DOMICILIARIES OF STATES OTHER THAN THE ST11TE OF PIARIDA:
er ec are t t my c e_ s n the State of
to permanently continue and maintain my domicile in sucn state.
declaration I am a bona fide resident of the State of
abode Withfn the State of Florida, if any, is as follows: (Heze
and county of place of abode in Florida.)
and that I intend
At the time of makinq this
My plnce of
l~st street address, city,
(Person makinq declaration may also include such other and further facts with reference to
any acts done or performed by auch person Which such person desires or fntends not to be
construed as evidencing any intention to establish his danfcile vithin the State of FloriBa.)
5162'76
1981 F~B -9 ~~ i~ 20
f ~L~C ~hC ~~ i,Ort~: 0
SLLUCIE CGUYTY.FtA.
FOGEFt POIiR,1S
Ci£AK f.;F~V3t C!?L'R:n
: , ~~•;:: , . . • ~~ -
(siqnature)
sworn to and subscribed before me this
day of , A. D. 19 .
r~otary Public State et Florida at Large.
~sy Commission expirea .
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