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p DECLARATION OF DO!~!ICILE
~~v
':o the Clerk of the Circuit Court (County Comptroller~ ~ p~ County, Florida.
This is my declaration of domicile in the State of .(o-t.(,c~G~. , that I am fi;inc
this day in accordance and in conformity with Sectio-ri~~, F ori a Statutes.
FOR DOMICILIARIES OF THE STATE OF FLORIDA:
1 hereby declare that I reside in and maintain a place of abode at ~y~,eL~/~,~/e
~street
ana-Ti'u er
~ , in S~- .~.UC 1 c..~ County, Florida, which place of abode I
city
recognize and intend to maintain as my permanent home and, if I maintain another place or
nlaces 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 makin this declara-
tion, a bona fide resident of the State of Florida residing at Yt leL~ A?F
• ' 1- (street and num er
~...VCI , in 5~- .~.-UC+~. County, Florida. I formerly resided at
c i~
Q U~e.~1S County, /,s1t ~ p/~/C , and the
U e.eCl .
city -T 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 places of abode.)
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~.1[Yc~l m ~'`s~r/~ ,c~r~ ~ -
I took u~ pe~i~t residence in sig~?at~e ;
~ ~ ~1 rn F r~ ~ ~ Q - (print n~e) ;
the state of Florida on 7- 85 • ~~~~dT r Lo,
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signature i
, (prillt ri~) '
~worn to an c~E'a,~ed before me this a3 da of
Y N ~ A 2y ? A. D. 19~.
;
,~a ~ ~ .
, ` ` ~
':otary 1~ State o,lorida at Large.
My Commisaion -~XPir~~ ~
~~cy v,~.r., c~ . ~ -~da ~ .~W 24 ~1 ~~6 ,
~ . ~ -=d'
% 1~
CQoimission Eip'aes Merch 4. 19~8
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V`^OWd ~M~ 110/ ~~y - {a>~~~~lY. M[~ FILEJ ~ . ' ~ U
; ~R PQIT'tZA~ , QEK[C G'IRCtTIT OOITRT ROGER ~ G ~ ~ ~ ; . , . -
ST. IUCIE (;~:~ti . ~ -
' ST . LUCIE OOL1rTIY , FLORIDA
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i~ni~~rir~iini~i~i~i
i~.i~i~i~i~~i~~i~i~i~~i~~i~~n~~~~~n~~i~~
:'~R DGMICILZARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
` hereby declare that my domicile is in the State of and that I intend ~
permanently continue and maintain my domicile in suc state. At the time of making this
_~~laration I am a bona fide resident of the State of My place of
~.~:~de within the State of Florida, if any, is as follows: Here ist street address, city,
~ ~:d county of place of abode in Florida.) .
'--~rson making declazation may also include such other and further facts with reference to
acts done or performed by such person which such person desires or intends not to be
~ :strued as evideneing any intention to establish his domicile within the Stat~e of Florida.)
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~ igzature
~ S wo to and Subscribed before me this day of , 19 .
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I~otary Public, State of Florida
~;~,`~K 454 PaGE 975
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