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UECII~RA'iZ~t OF D(~~QCIIE ~ '
SfATE OF FTARIDA
04lNTY OF ST . LUCYE
Ttiis is my Declaration of Doaticile in the State of Florida that I am filing this
day ~n accordance and in ca~for~dty with Sectiari 222.17, Florida Statu~es.
I~~)~ ~5
. P ease pr t yowr name c ear y
became a bana fide resident of the State of Florida an = R 1~ 1~_~!~
a:td I reside at ~.1 ~ L .~~p A•J ~ 6T t~~ •
` in the City of ~~'f" S~ ~L.
My m~il ing address is : a, ~
erent s~-xeet a ess
T ~ C-2L -
My fonrer legal resider?ce was in the City of ~P?~ (Z ~ Pt~ K-S
State~ of ~~~L(~-
.
(No ivrther statem~nt is required. Hawever, if you wish, you may insert any
pertinent facts such as sale of property or business or relinquisturent of .
enploynrnt at forn~er danicile, rennval of faQri.ly to new domicile, purchase of
home, etc.)
I FUR'I~~IIt f~RTIFY I wiii c~mply with all requirements of a legal resident of
this State. I vnderstand there is a pena7.ty for perjury; per'ury is a Felony
~d is punishable by incar.ceration in t~he S*3te Lment o~Ca tians.
t~ . `
PR NE1ME SI W
PRINT NAI~ SI Tl.
THIS SPACE FOR REOORDING Il~RMATI(~I
•~t,~iTi ro.and subscribed before me this
. day af 19~_
~ ` ~ •J •
. ~ DoUC~S DI~N t~,ERK CIFtCtJI'T CT. ~~~40
.
` ° :
: ~ br '87 JAN 19 A10 :0?
. . . . Deputy Clerk
. Fi~eo ~~t~ :
.
Notary Public, State of -
My Caca~ssion e~ires :
Eseal) ~
,
~ • ~OJ~',29 P~Og21
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