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N~.TI~11.~..01r.
DOM~CII~.E _
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.To tha Cierk pi~ th~ Circuit Oourt iCounty Caaip~roli~r~ Q.. • County, Florida.
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~iis is •y declaratioa ot da~icile i~ th~ Stat~ of t- I r'~ , that 1 aa~ tiliag
,this day i4 accordance aad ia conforoity vith.S~ction 3~. , os Ca $tatutes.
FOR DO!lICILIIIRI~ O~ TaE S'rATE O! l~LCRZOAs
I h~r~by decli~re that I reside ia and ataintain a placa o~ abod~ at . 8 ~G 61q - t~ •
a ree aua niimT'eT
, ia . L~~
P~,_~ ~~ty, l~iorida. Mhich pla~~s of abode I
tci~y
reco~nise and intend to ~aaintafn as ary pesa~anent hase and, it I naintaiu another place• or ~
places of a?bode fn so~as oth~r stats or states, I hereby declare that my above-deecribad
residence aad abode ia the State o! llorida aoAStitutes ~sy pradowinant and principal hcwe,
and I intend to continue it persaneatly as such. ~2 a~s, at th~.t3~e f ing this l~ra-
tion, a~boaa lide resident ot ths State ot llorida reaidinq a! .
ree an n r
Q,~- o_ in lrt)G_~_ County, l~lorida. T~orweray resided at
~ y ~ . ~-1-1~~~ Conaty, , and tbe
c y ' ~s~~f"" •
place or places Whera i maintain aaothes or other pZ~ce or places ot abode are as follo~ss
(Here list street address, city, county and state o~ any other plaae or places of abode:)
I tvok up pe~marazt residenoe in s t~e
?c~ r~n~ ~~~st Cin ~ n.s _ ~,t ~oe
the state of Flarida an -'1 . i
. . s gna ure
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Sworn to and subscribed before me this ~~day of ///GZZ.~Y • A. D. v l9 ~7 _
~ ~ ~ .R CQRDEQ
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~ouNr,, S~ UC~ ~ ~L~~TY
Notary c tate o ori a a e.
t~ly Ca~amission expiras µE~ C ,
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~ 8~ MAR IS A~~ ~ 25 -
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im(ER POITRAS, QERK QRaJIT QOURT ~:o ~
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`~~E COUMI'~ •f~ f VI ~1f+1J
sr. ux~ aat~nY, CiLERK CIRCUi~ COURT
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FOR DOMICILIARI&S 0~ STa1TBS OTHSR THl~N TAS STATB OF PIARIWiIs '
I hereby declare that ay domicfle is in the State af and that I intend
to permanently continue and maiatain my da~icile in suc sta.e. t,i~me of makinq this
declaration Z am a bona fide resident of the State of . My place ot
abode vithin the State of Florida, it any, is aa folloas: ere s~treet address, city,
and vounty of place of abode in ~lorida.) , .
(Person a~aking declaratian .may a~lao include such other +and furt2~er facta tiith zeference ta
any acts done or performed by such person vhich such person desires or intends not to be
construsd.as evidsncinq any intentioa to establish his doAicile within the State of Florida.)
~ gt~ttse .
' Sworn to and Subscribed before me this day of , 19 ~ .
Notary Riblic, State of Fl,orida . . B~ ~ t~ ~
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