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STtiTE OF i'I.OR T QA (;~~ii..'9a.~.r+~.+ j
COUNTY Or ST. LUCIC
This is my Declaration Uomicile in the State of Floridn that I am Eiling this '
day in accordance and in conformity with SECTION 222.17, Florida Statutes. ~
G
I , ( ~de ) , ~.ni iiv~S ~i9/L Al~ D
p ease p int you~ name c ear y
became a bona ~ide resident of the State oF Florida on /~~U 7, 19
and I reside at o~~0~3 ~G--$~2AS,~A ~(~~~uc ~
in the Ci ty of ~or~r- /~/~Pr_~-
My mailing address is:
if different rom street address
My former legal residence was in the Ci~y oF ~ P/~i~ ,
State of ~X~S •
(No Eurther statement is required. Hotaever, 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, purctiase oE
home, etc.) ~
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~ I FURTHER CERTIFY I will comply with all requirements of a legal resident of
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this State. I understand there is a penalty for perjury;perjury is a Felony
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~ and is punishable by incaration in the State Dep tment of Corrections.
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~ PRINT NAME IGNATURE
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I PRINT I~Ar1E SIGNATURE
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Sworn to and subscribed before me d~y of , 19-^~~~~
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ROGE ITRA C ERK CIRCUIT C1'. w~t ~t ~~~:.c_~~
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D~puty Clerk
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RECORDING INFORMATION
Notary Public, State of
~1y Commission expires: ?'7~~9„1,2
(seal)
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