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SYATE OF FLOAlOA)
COUNY'Y OR sT. LUCIB ~~~~y`j .
This ia a~y Declarati~on ol 0oealcl~ In th~ 8tete ot Fto~ that I am tilinp thia day in aocordanc~?
and tn conlo~~ wftA 8~ctlon 2Z21 T~ Florid~ Statvtes. ~
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p~ew Nra ~+o~w w~w aaM?n
DOCatT10 0 bOt1s ~O fr8ldNlt 0~ ~~!0 0~ f~lOtldA Ot~...y~~' 9. - 9 ~
end I re~ds at,..~ a- . V 7-a-. l a c~ i~. ~a o ~
In the City ot ~o R Y' s T ~l, u. c. a. .
My meiltrrg addross lac
aM a~s a~o~ awsr ~oo~sa~
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, My tormer !e~! residsnoa wea !n ths City ot a, N:g ~~q~~ _
Ststeo! ~~~h i~a~?
(No tuRher atete~t !s roqulred Wo~w~sver. M you wish, you may tnsen any psntne~t tacta
such as aals ot propartyorbuelnses ornqt~qutshment ot smpbyment et tormerddrrildtq, remova!
ot Iamtly to new don~ldttor. pur~hsse of hom~ eta3
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1 FURTHEA CEATiFY 1 wlp oompiy wtth tequuementa af e ispel reskfent o! thls 8tste~ 1
understand thero !s s pettstt~/ tot pehury; psrJury is e Fefo~y and ~a punlshabis by 1nc;~r~tivn M ths
~ State Da~artnaont Qt Comectlona~.
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