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542580
DECLARATION OF DOMICILE
To the Clerk of the Circuit Court [County Comptroller~ ST. L UCIE ~ County, Florida.
This is my declaration of domicile fn the State of , that I am filing
this day in accordance and in conformity with Section ~~~oid~a Statutes.
FOti DOMICILZARIES OF THE STATE OF FLORIDA:
I hereby declare that I reside in and maintain a place of abode at OZ ~ Z Kll ~C'
~ street an n er
, in ST. LL1C 1 E County, Florida, which place of abode I
clty
r~cognize and intend to maintain as my permanent home and, if Z maintain another place oz
olaces 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 ti,~ne Dof ma~kinq this declar -
tion, a bona fide resident of the State of Florida residinq at 1- LF~/U~I~LC- l~ ~1~~
J ~ street an n r
~Q , in S • Q C i~ _ County, Florida. I formerly resided at
/l~p~ ~5~~ . ~ County. h I~J~ . 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 st e of any other place or places of abode.)
I B£ CAMlE A RES I DENT ON THE' ~AY OF u i(d~ ~ 19~. '
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.~~.,c •9 ` ,..^i.• ~'v~ ^ signature
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Sworn to and subscribed before me this ~ day of . A. D. 19
ROGER PO I TRP S, CL ERK C i RCU I T COI~t T
ST. LUC I E COUNTY, FLOR I DP
Notary Public State of F orida at Large. j ~
My Commission expires B Y~ ,K~.L vl
~~~~~~~~E P U T Y C L E R K
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j FOR DOMICILI?~RIES OF STATES OTHER THAN THE STATE OF FLORIDA:
~
I ere y declare t at my domicile is in the State of and that Z intend
~ to permanently continue and maintain my domicile in suc state. At the time of making this
` declaration I am a bona fide resident of the State of My place of
i abode within the State of Flor~da, if any, is as follows: Aere ist street address, city,
~ and county of place of abode in Florida.)
(Person makinq declaration may also include such other and further facts with reference to
~ any acts done or perfoxmed by such person which such person desires or intends not to be
construed as evidencing any intention to establish his domicile within the State of Florida.)
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~ 542580
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~ signature
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~ ~worn to and subscz~ibed beforQ me this day of , A. D. 19
~ *~otary Pub ~c State'o Flori a at Large.
My Commission expires
r 800K~J PbGE J~4