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DECLARATION OF [~OMICILE ~~O ~
ttie Clerk of the Circuit Court (C~unty Comptroller) County, Florid
: h: i s~,v decl~zation af d~:nicile in the State of ~ , t'~at I am f il ing
:.his da~~ in .tccordance and i~ ocnformity with Section ~ . , F or~c~a
Stt~tutes.
,
~ ~C'.!ICiL.At?IES OF Z'};E S".'ATE Of'. F1.ORIDA:
._'~~~rec,}• decl ~rE ttiat I resi.le ir~ an~ maint3in a place of abo:'.e at .rs'/ ~
stree-'t~an~ er
f\y~ • , in ' County, Fl.orida, which place of ahade I
~ic:~~ ~ .
7r~i a:s.i ~s~t:~n*i to *d:ilT~ialll as ml pci-man~nt home and, if Z maintain another place ~r
; ta:•~ ..,f ~bo.:~~ iti ~{..-s~~ ocler titate states, I hereby 8eclaYe that my above-des~ribed
res_der.~e and aboci.~ in tRa State of Florida constitutes my predominant and principal home,
and L inteiid to cor.tinve i~ Ferm~~nently as such. I am, at the tir~e- of~ t!~akinq this de~ara-
• i:-.n., a~cna fidz resi~3ent of th~~ State ~f Florida residing at f~[ ,
• ~ " street a nur~ e~
, in County,. Florida. I formerly resided at
cz y - n •
, `~~~y County, , and the
ci y state
::ace :~r ~laces w ere I maintain another or other plaee or places of abode are as follows:
~~i~re lis± str~et address, city, county and state of any other place or places of abode.)
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. '~?aa ~AT ~G . f 6.G- s <pr~?r
:~o::l• t;{• ~ nc{,; s}tbscc~b~u re=c~re r.:._ this ~~~day of ~ ~ A. D. 19~
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~ ~xe~ I9~4 JAN 25 ~!t ~S 35
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~ 'a JOM?^ILiA£~:ES OF S2'ATES OTHER T?i4lv ThE STATE OF FLOR2DA:
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~ ~er~b; c,~:are that m;~ domicile is in th~ State af and tna~ I intend
~ Yez.T,aner;l}• continue and :naintain my dom:cile in suc state. At the time rr,aking this
.~laration I am a bona fide r~sident of the State of . My place of
F ,:~c,dp wit~in the ~tate of Florid~3, if any, is as follows: Nere ist street address, city,
:~,d c.,~nty cr place of abode in Fl.,rida. ) ~
~
~ "~~r:~or: :~,lkir.r, declaration may aiso inciu~e such other and further facts with rc~fererce to
~ .,:cts dor.e or perfor:r.ed by such per~on waich such person desires or intends not to he
~ ~~*_:~ed ~s Avidencir.~ any intention to establish his domicile within th~ Stat~
or Fi~ri~a.)
~ i~ature - - .
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~ . • . . .'u:~: ~ ri?~~•:i `~~~t: rn~ tt~i5 day of 19
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