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DECLARATION OF DOMICZLE
STATE OF FLORIDA )
COUNTY OF MARTIN )
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This is my Declaration of Domicile in the State of Florida
that I am filing this day in accordance and in conformity with :
,
Section 222.17, Florida Statutes.
I, we,~Ja~~ e ~~NNi E 1~.~i31 St~
( Print Name C~early) ~R ~ - f ~
became a bona fide resident of the State of Florida On i
and I res ide at~~ C D S(a ( A- l~ N?? ~C L L N/~ ~/,~L L AS ~
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s T J,~"`''G C~G .DG ~
in the C ity of~~ c L~,/ ~lsi~? County. a 3 ~
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My mailing address iss ~
(If Different from Street Address)
My former legal residence was in the City of F~ Ie M t~ T~ l1~ ~~S
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State of f-/ rl n) '
(No further statement is required. However, if you wish, you
may insert any pertinent facts such as sale of property or business
or relinquishment of employment at former domicile, removal of
family to new domicile, purchase of horne, etc.) -
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I FURTHER CERTIFY I will comply with ail requirements of a
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legal resident of this State. I understand there is a penalty for ;
perjury; perjury is a F'elony a~d is punishable by incaration in the
State Department of Corrections. ~
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(Signa re)
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, ~ ~ _ ~ ~ ' ( Signature )
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S~+o7Cry to and subscribed before me ~~6 ~F~ _9
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this1=day of ^ , 19~. ~
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Notary ublic or other Off'cial Taking
Acknowledgment 9y~
NOTARY PUBUC STATE OF FtpR~DA
My Commiss ion Expires : MY C~M~''~~55?~N EXplRFS MqY I6 1986 a p~{jC.
BO~~DED INRU GEr~ERtil Ir~S . U;~~FR~~.~R!rFRS eG~~ '~U :'A:;~ %
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