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S"1'A't'l: O[•' l~ i.Oft i DA
CUUN'1'Y ON 51'. Ll1CIC ~~9~
This is my Declaration Domicile in the State of FZorida that I am filing this
day in accordance and i~ conformity with SECTION 222.17, Florida Statutes.
i , ( W e ) , c ~w..~Q."C
p ease prin your name c ear y
became a bona f ide residenC of the State of Flori s on 19~c~ +-i
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and I reside at _
i n t h e C i t y o E p;~~r,r ~
My mailing address is: ~jc~..v~.~ }
i dif ~eren rom street a dress
t
My former legal residence was in the City o~ ;
r---~
S t a t e o f -1-- hc~ ~ o.~c~ , ;
i
(No further sta~ement 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 domic~le, removal of fami.ly to new domicile, purchase of ~
home, etc.)
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I FURTHER CERTIFY I will comply with all requirements of a legal residznt of
this State. I understand there is a per.alty for perjury;perjury is a Feiony
and is punishable by incaration in the State Department of Corrections.
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Soy c~ ~ - v.,.~t ~
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PRINT NAME S A RE
PRIt~'T NAME SIGNATURE '
Sworn. ~t'o ~attd` subscribed before me this ---J=~--day of , 19~_
ROG ~'bITRAS;. ~~LERK CIRCUIT C1'
8y ~ -
' t er
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' RECORDING INFORMATION
>otary .Putilicu State of ,-~?~69~
~ ~ty Commissior~`: expires:
'8b i 9 P 1 :03
~ seal) .
RQGEr
ST. LUC~E _
51~. ~f 995
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