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51'~383
DECLARATION OF DOMICILE
To the Clerk of the Circuit Court [County Comptroller) St Luci e County, Florida.
This is my declaration of domicile in the State of Florida- , that I am filing
this day in accordance and in conformity with Section f~T~, F ot r~da 3~tatutes.
~OR DONICILIARIES OF THE STATB OF FLORIDA:
1 hereby declare that I reside in and mafntain a place of abode at .
s ree an n er
~t $~.~~ie County, Florida, which place of abode I
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recoqnize and intend to maintain as my permanent home and, if I mafntain 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 home,
and I intend to continue it permanently as such. I am, at the time of makinq this declara-
tion, a bona fide resident of the State of Florida residinc~~ .
street an n r
Fort Pierce , in St Lucie County, Florida. I formerly resided at
(c~ty)
County, *'ew 7ers,e~ , and the
~ . cit~ ~ ~ ~state)
place or places where I maintain another or other place or places of abode are as follows:
tHere list street address, city, county and state of any other place or places of abode.)
I have been residi:~c~ at 5O3 Ulrich T;oad since October 21~ 1980.
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SwQ~'~} r.',3rt , Cr~d before me this ~ day of ~~_ , A. D. 19
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ot ' 1 "St,s~e_: of ~lorida at Larqe.
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FOR SStk~ICx~T~-iti~S OF STATES OTHER THAN THE STATE OF FLORIDA :
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I hereby~declare that my domicile is in the State of and that I intend
to penaanetitly continue and maintain my domicile in such state. At the time of makinq this
declaration I am a bona fide resident of the State of . My place of
abode within the State of Florida, if any, is as follows: (Here list street address, city,
and county of place of abode in Florida.)
(Person making declaration may also include such other and further facts with reference to
any acts done or performed by such person which such person desires or intends not to be
construed as evidencinq any intention to establish his domicile within the State of Florida.)
51'7383
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Csignature)
Sworn to and subscribed before me this
t~otary Public State of Florida at Larqe.
"iy Commission expires .
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_ e^' .-s:;'i..A z~...". .....
day of
BO~KJ4p P~GE2~~
, A. D. 19 .
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