HomeMy WebLinkAbout0995 ~C~.l~lllll~lli~ ui ~Ys~~sa~ss `J,
a"1'A'I'L•: Ut~ I~ t.Ott I DA
COUN'('Y UN S'I'. LUCI~
This is my Declaration Domicile in the State of Flarida that I am fi].ing this
day in accordance and in conformity with SECTION 222.17, Florida SCatutes.
I~~ We I?~'~it ~N ~G ~ s ll ~ ON f~ v~ I S~D r h L l,v M~ ~~.Q ~ ~
p ease print your name c~ar y
became a bona fide resident of the State o~ Florida on 19
and I reside at~_~ ),T
in'the City of ~eNY' ~SJ' LUc~ ~ • ~
My mailinR address is: ~~~_q ~)v a
(iE differe`nE ~rom street a ress~
~
My former legal residence was in the City of ~~.-t' f~i,~ ~.e~c~ - ?
State of ~
.
t
(No further statement is required. However, if you wish, you rray 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
home, etc.) ~ `
I FURTHER CERTIFY I will compl~ with all requirements of a legal resident of
chis State. I understand there is a penalty for perjury;perjury is a Felony
and is punishable by incaration in the State Department of Ccrrections.
~3,~.,,, 1~i ~ f ~ ~ ~r ~
PRINT NAME SIGNA UAE
PR~NT l~AP1E SIGNATURE
~~~Y _
O q, .
Sworn to and subscribed b~ t~t~ day of - , 19
, ROG POITRA5, CLERK R `6 ~ '
' ~ ~ J''~' O . I
BY v.?- ~ ;
' De y erk ;
"T l;;C~E
~ RECORDING INFORMATION
~ {otary Public, State of _ _
~
~ `t> Conmi s s ion expires : ~'76e~$~
; s e a I) 'E5 AUG i 9 P 1:03
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ROGE . ,
ST. C,E _ ~ •
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