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DSCLARATION OF DOMICILE
To the Clerk of the Circuit Court [County Comptroller~ ~ , e Couhty, Florida.
This is my declaration of domicile in the State of ~ , that I am filing
this day in accordance and in conformity with Section or a tatutes.
FOR DOMZCILIARIES OF THE S~ATE OF FLORIDA: ~
I hereby declare that I reside in and maintain a place of abode at r"(~IM~
~ s ree an n er
~~_~'~L~ ~ , in ~ K G. ~ County, Florida, which place of abode I
city _ ~
recoqnize and intend to maintain as my permanent home and, if I maintain another place or
places 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 haae,
and I intend to continue it permanently as such. I am, at the t' of ma~i his ~eclara-
tion, a ona fide resident of the State of Florida residinq at 13 3,Z1J.~ ,J 1l~. .
' street n r
-~~l , in ~.~KC ~ County, Florida. fo rly resided at
c
O . J~~/ County, ~~1~1CG G , and the
city s a e ~
place or places where I maintain another or other place or places of abode are as follows:
(Here list street address, city, county and state of any other place or places of abode.)
I took up pe~ent residence in - s ~e
e ' (print nare
the state of Florida a1 4J' • ~
siqna ure
. (priilt
Sworn to and subscribed before me this ~day of , A. D. 19 8~
~
Notary pu ic State o F ori a at Large.
My Commission expires • 6~j~,24 -
' I~;GER POITRA.S ~ QERK CIRCUI ' OOURT ~
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j ~T;': . OOi)N1Y ~ FI.~ORIDA
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d FOR .Dd[~I~CIL~A~~F STATES OTHER THAN THE STATE OF FLORIDA:
g . ~ i _ . ~j~ •
I her~b~~clat~~e that my domicile is in the State of and that I intend
to permanently continue and maintain my domicile in suc state. At t e time of making this
declaration I am a bona fide resident of the State of My place of
abode within the State of Florida, if any, is as follows: Here ist street address, city,
~ and county of placa of abode in Florida.) -
~ (Person makinq~declaration may also include such other and further facts with reference to
~ any acts done or performed 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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~ S worn to and Subscribed befare me this day of , 19 -
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Notary Public, State of Florida
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