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STATE OF FLORIDq) ~16SS3
COUNTY OF ST . LUCIE
This is my Daclaretlon of Domicile in the Siate of Fiorida that i am filing this day in accordance
and in co~ton++ifi+ with Section 222.17~ Florida Statutea
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beCama a bona fide rosident ~ the 3tate of Flortde on_ ?vs~~ _~3 4~5
end 1 reside at ~53 ~ ~~9~ ~s/ ~ /~1 ~
in the City of 1/l'~s"~y ~~-~j
My mailing address la
(IF DIfFERENT FROM STREET AODRESS)
My fonner le~al res(dence was in the City of ~~'-=~h
State of ~'Dy"~"
(No further statement Ia required. However~ i~ you wish, you may insen any pertinent facts
such as sale of property or business or relinquishment ot employment at former domicile~ removal
oi family to new domicile~ purchase of home. eta)
1 FURTHER CERTIFY 1 will compiy with all requirements of a legal resident of this State. I
understand there !s a penalty for perjury; perjury is a Felony and is punishable by incaration in the
State Department ot Correctlons. ~ -
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PRINT NAME SIG TURE
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~ ~ INT NAME ,-GNATURE
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~ _ THIS SPACE FOR RECORQING INFORMATION
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~ ~to~r?d suDacnbed betoro me thla . aay 'ffi 24 P 1:07
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~ Deputy Clerk ~`~`~~a3
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Notary Public~ State of
~ My Com~tission expires:
~ FORM 20
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