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6
i~203
DECLF+FtATION OF DOMICILE
To the Clerk of the Circuit Court [County Comptroller] 57, l~c~G County, Florida.
This is my declaration of domicile in the State of F loR,o,~ , that I am filina
this day in accordance and in conformify with Section F ori a Statutes.
FOR DOMICILIARIES OF THE STATE OF FLORIDA: ~
I hereby declare that I resid` in and maintain a place of abode at i'L3~ 5~ LAON~t~ ST ,
~oR~ S~. ~~c,~~ street an r.u er
, in S-T. L ~c~t County, Florida, which place of abodP I
city
recognize and intend to maintain as my permaner.t home and, if I maintain another place or
claces 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 home,
and I intend to continue it permanently as such. I am, at the time of making this declara-
tion, a bona fide resident of the State of Florida residing at ~'i3? S~ ~AOr.ieR ST ,
--~treet an num~erj
P~~t Sr. L..c~e. , in S-~. L~c?c County, Florida. I formerly resided at
Zcity i
h~lno \ t,~A , Ph~ia~tlpti.q County? ea,N ~vnN~ , and the ~
city state
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 piaces of abode.)
L~C~ ~
Z took up perm~ient residence in slgr~at~e
- ~ t , ~ (print name)
the state of Flor~da on ~ o-, g y • •
si nature
11 , (PrinC name)
Sworn to and subscribed before me this ~ day of ~~,~,Q,(,~p,~, , A. D. 19~.
*~otary Public State o Florida at Large.
!~:y ~ommission expires ~ a+,j ~Q P3:~$
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: ~ ' ~ FILED " . ;
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` =~R~R~ POIT~S; ~QFRK CIRC[TIT COURT ROGER F,::
; • ~ , . _ ST. LUC,E . . . _
I s~ . ulc~ c~;~ =~oxznA t 6'7'6203
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FOP. DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
I hereby declare that my domicile is in the State af and that I intend
~ to permanently continue and maintain_my domicile in suc state. At the time of making this
ceclaration 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,
~^d county of place of a~ode in Florida.)
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!Person~making declaration may also include such other and further facts with reference to
a^y acts done or p~rformed by such person which such person desires or intends not to be
~onstrued as evidencing any intention to establish his domicile within the State of Florida.)
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~ Swc~rn t~ ~d Suhscribed before me this _ day of , 19
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Not Public State of Florida C~ t~
~ ~ 600K ~~v PAG~
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