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STA7E OF Fl.OAlOI~ '721052
COUN7Y OF ST . LUCIE
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This is my Dectaratio~? of Domicfla in the 3tate of Fiorida that i am tilin~ thia day in accordance
and in contan*+iN with Sectio~ 222.17~ Florida Statutea
~y~e~ ~.jni~ . ~ -nd,~. .~-~T~#q~
-T • (REASE PRtNT wWE CL~i1Ni1n
became a bona ti~de reaident ot the State ot Ftorid~ on~ ~ 5 ;
I ~ a Cu t--}'i' S~-~}'r c~~" f
and 1 reside at ~ _ i
in the City of ~ ~'1 • kGi C ~
My mailing addreas ia
(IF OIFfEHENT fROY STREET ADDAESS)
My former legal residence was in the City of L-OY' iS _ ~
State of l ,cl.ra ~i na~
(No further statement Ia required However~ if you wish~ you may insert any pertinent fects
such as sala of property or businesa or relinquishment of empioyment at former domicfle, removal ~
of family to new domlclle~ purchase of home. eta)
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1 FURTHFR CERTIFY I will comply with all requirements of a legal resident of this State. 1
understand there is a penalty for perjury; perjury is a Felony and is punishable by inca~ation in the
State Department oi Corrections.
~Ch a. STAG~' ~~1.
PRINT NAME SI NATURE
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PRINT NAME SIGNATURE
TNIS SPACE FOR RECOROING INFORMATION
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~ ~ ~ ~ 19_ '85 At1G 22 P3 ~30 ~
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~ P't~2~S:, CLERK CIRCt'TT CT, fILEC ' _ .
; t~- . _ ROGER ~ . . _ -
° ST. LUCI~ ~'U~• r. ~ L
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~ ~ . - ~ '721052
Deputy Clerk
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Notary Public, State of
My Com~ission expires:
FORM ZO
(seal)
47~ 9~i
~OOK PaGE ~
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