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51~~68
DECLARATION nF A~~7ICI:.E `
To the Clerk of the Circuit Court [County Comptroller~ ST. L UGIE County, Flori@a.
This is my declaration of domicile in the State of~ ~•`_1~ rida , that I am filing
this day in accordance and in conformity with Section ~33~, Florida Statutes.
FOR DBMICILIARZES OF THE STATE OF FLORIDA:
I hereby declare that I reside in and maintain a place of abode at 1809 Lin~voo e ,
( street ana nu~^.fler
. r~o , in ST,, l UC 1 E Connty, Florida, which place of abode I
city;
recoonize and intend to maintain as my permanent hcme and, if I maintain another place or
~iaces of abode in some other state or states, I hereby declare that my above-descri3ed
:esidence and abode in the State of Florida constitutes my predominant and princiral ha~e,
and I intend to continue it permanently as such. I am, at the tim~ of makina this ::ec:ara-
cion, a bona fide resident of the State of Florida residinq at •„ ,
street an ~u^~::~er)
f~ort Picrce , in St~ LuciF County, Florida. I formerly re~i~ed at
(city ) sr~,e;,;~y
Vero ~ . Indian Rivcr County, ~~~ ~,-; ~a , and the
city) state
~lace or places where I rr.aintain another or other place or places of abode are as fo;laws:
°~iere list stzeet ad~ress, cit}•, caunty and state of any other p2ace or p:aces of a~c:e.)
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_, , signature ~~~~2~~
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'~Prson making declaration may also inclvde such other and further facts with re,fer~,~-f to
=-~y acts done or perforrzd by such person which s~ch person des?:es or ir.t:_nds r:~i ~o :_
..~nstrued as evidencing any intention to establish his domicile within tr,e State cf ~: __:a.)
Sworn to and subscribed before me this ~ day of , A. c. 19~.
~ ROGER PO i ~ S, CL ERK C I RCU I T COlk2
ST LUC I E COUNTY, FLOR I DA
'~~tary Pubiic State of Florida at Large.
My Commission expires . BY . E Pu; Y C L E
FOR DOMICZLIARIES OF STATES OTAER THAN Tf~ STATE OF FLORIDA:
~~ ere y dec are t at my omicile is in the State of and that I ir.tend
-~~ permanently continue and maintain my domicile in such state. At the time of makin~: this
~-claration I am a bona fide resident of the State of . M:r T~1dCr' Gf
~:~de within the State of Florida, if any, is as follows: (Here list street a:dress, -~it}-,
~:.d county of place of abode in Florida. )
j ~ 51'7368
~I fE~ 18 PM 1~ 27
F~LfC ~~+C ~` COF!!! ~~ ~
~ i. LUCIE CfiL'N' Y. f l~.
AOGER POITR~t n ~
CIERK C,FC~~ ~
,,t~vf, ~: n~~.~ ..
4c • -
sworn to and subscribed before me this
'+otary Public State of Florida at Large.
~:y Commission expires .
(siqna~ure)
day of , A. D. 19
$~348_p~s~616,
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