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DECIJIWITION OF DOMICTLB s~~.~j
To the Clerk of the Circuit Court (County Canptroller~ ~ Caunty, Florida
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This is my declaration of domicile in the Stnte of , that' I am fi:inq
this day in accordance and in contoriaity rrith 5ection or a tatutes.
FOR DOi~IICILIARIES OF THE STATS OF FLORIDA: ~
I hereby declare that I reside in and maintain a place of abode at
~ ~ s ree an u er
, in County, Florida, which place of abode I
c ~ ty
recoqnize and iatend to maintain as my pennanent hwne and, if I maintain anothcr place cr ~
Flaces of abode in some other state or states, I hereby declare that my above-described .
residence and abude in the State of Florida constitutes r.~y predominant and principal ha~n~,
and I intend to continue it permanently as such. I am, a~ the time o m nq clara~
tion, a bcna fide resident of the State.of Florida residirg at /0 ~ ,
~~n ` street num er
~O~f- 5~~ , in County, lorida. I formerly resided at
~~ty i ~ ~~73
, County, , and t!:e
ci te
place or pl s where I maintain another or other plzce or_piaces of abode are as follows:
(Here list street address, city, county and state of any other place or places of abode.?
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I took up pern~ient residen si~
~f ~ O S~ v~~3 6-L.l Y-~- (print na:
the state of Florida an ~j ~l . ~ - _
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~ siqnature
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Sworn to and subscribed before me this ~ day of ~ , A. . 19~..
rtotary Pu lxc State o F ori3a at Large.
M;~ Commission expires ~ F~~ 2 ~ 3~
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'O~ DOMICZL~~RB$S ~1Fj'~TATES OTHER THAN THE STATE OP FLORIDA :
hereby deolare that r~y demicile is in the State of and that I intend
c permanently continue and maintain my domicile in suc state. At the time of r~aking thi~
cclaration I am a bana fide resident of the State of My place of
~:ode within the State of Florida, if any, is as follows: Here ist street address, city,
~ nd county o: place of abode in Florida.) "
Person makinq declaration~may also include such other and further facts with referen~e to
~ n; acts done or performed by such person which such person desires or intends not to be
~nstrued as evidencing any intention to establish his domicile Within the State of F1^ri~a.?
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~ g~attae
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~ Swom to and Subsrribed befare me this day of , 19
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i~htary Publi~, Sta~e ~f Fl~da ~ ~
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