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D1DCI.11W?TI~N 0~ DOMICtI.~ .
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zb the Clerk o! th~ Circuit Court ICaunty Co~ptroller) ~~,`~~i„__ Cou~ty. ~lorida.
This is my decluation o! dveatcile in tha Stat~ a! ~~t~rielA , th~at I as iilinq
this day in accordanc~ a~ad in conlorsity ~rith. S~atiou . , or`i3a-$tatutes. ~
p'QR DOMICILIARI&S Ol~' THE 8TA?8 OF 1~LORID11s
t hereby aeclars that I. reside in and maintafn a place o~ aboda at~~l~/7 ~~AA/~
~ ""'"r's ree an~ A ~r ~ ~
~ ~~,~Q , in , LJ_~~_c,~i_,~,_,~„ County, • l~lorida, whicb plaa• o~ abode ~
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recognise and intead to maintain aa my penaaJ?ent ha~e.and, if i~saintain anoLher place~or.
places of abode in some other state or states, I hereby declars that my above-describ~d ,
residence and abode in the State ot Florida constitutes ay predaainant and principal.haae,
and i~intend to continue it penaanently as such. Z as, at ths time ot akinq t is eolara-
cion, a~ bona fide resident of the State a~ Florida iasidinq at_Z~ ~r w_ ~
~~5 j - ~ a ee . an nu~Ti=F-
, i~ s'~, ~uci County, Florida. I los~nsrly resided at
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,l,~~ ~ T~~lTtZ~t.1-~ c~u~ry, snd the
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place or places Wt?ere I maintain another or other place or places of aboda are as tollows~
{Here.iist street address, ciiy, county and state of any other place or places o~ abcds.)
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~ took up peYmac~ait residence in - s tvre - ~
<,~1 _ ~'tt_~ ~ ~t ~'J~~int nacoe)
the state of Florida an , ~ , .
~ s qna e .
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Sworn to and subscribed~before me this day of ~ D. 19~. '
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:votary Pu ic State o r ori a at Larqe. - ~ F~ _8 5 •
My Co~ission irea • 4
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FOR , I~• ,,~ATES OTHER THAN TEiE STATE OF FLORZD~:
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I heroby dealar " t eay domicile is in the State of ~ and that I intend
to permanently tinue a?nd maintain ray domicile in suc state. At t e time af makinq-this
3eclaratfon I am a bona fide resident of the State of ~ My place of .
abode within the State of Florida, if any, is as fol2owss ere st street address, cfty,
and county of place of abode in Florida.) .
(Persan makinq.declaration may also include such other and further facts with reference to
any scts done or p~rformed by such pexson which auch.person desires or intends not to be
construe8 as ~vidancinq any intention ta establish hia daaicile within the State of Florida.~ .
g~at~e
Sworn to and Subscribed befare me this day of , 19
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I~btary P~blic, State of Florida .
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