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STATE OF ~LORiOq)
COUNTY OF ST. I,UCIE
This is my ~eclaretion of Domicila in the State c~f Florida that 1 am fili~g this day in accordance
a~d in conio?~~tv wilh Section 222.17, Fiorida Statutea
~We~ G~//<<.r ~ _
~ ~PLEASE NT YOUR N/WE CIEARLI~ I
became a bona ftde rosideni of the State of Flarida on_ ~v~.l~'" ~
and ! reside at~ ~23Z ~C r ST~E`~'f'
in the City of ~ s~~ S 2_..
My mailing address ia ~S~t
pF D1iFERENi FitW/ STFtEET ADORE55) ~
My fonner legai residence was in the City of _ TA~~.~~~~
State of__ fLCYlrt~
(No further statement is require~d. However, if you wiah, you may insert any pertinent facts
such as sele of property or bUSiness or retinquishment af emptoyment at former domicfle~ removal
o~ iamify io new abmiciie, ~~~~a~~ ai i~i~~„~. ~t~.j
_ i FURTHER CERTIFY 1 wiit comply with ali requirements of a legal resident of this State. t
understand there i~ a penalty for perjury; pe~jury is a Felony and is punishable by incaration in the
State Department of Corrections.
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An') 1~,~E~i' ~it/ ` ~
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PRINT NAME SIGNATURE
PRINT NAME SIGNATURE
TNIS SPACE FOR RECORDING INFQRMATION
swa~ ~o a subscribed betoro me cn~s i~ ~y '85 ~ 24 P 2~23 0
of _ 19~ -
FiiEr
RGG~~
ST ;.ti:
ROG POITRAS, C RK CIR~'.'TT C'_r,
.
By . '71661Q
. Deputy Clerk
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. ,i~;~ Notary~Pzib~lic, State of
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".ki'yr;Eb~attission expires :
_ i~ORM 20
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