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~ecl~rnti~n uf ~ormirtle 811928
STATE OF FLORIDA
COUNTY OF ST. LUCIE ;
F
This is my Declaration Domicile in the State of Florida Chat I am filing this :
day in accordance and in.conformixy with SECTION 222.17; Florida Statutes. #
I, (w~>, ~a - ~o r~c~ S ;
" p ease pr nt your name cTear y ~
became a bona fide resident of the State of Florida on ~-I 19 ~ 1 `
~
and I reside at IZ3o 0 rrr,~vc~ O~v~
in the City of ~~c c.e ~1~- L 33~} S~.
My mailing address is: bZO~ ~a~ r,.~. ~~v~c.r ~T a~i-~'~~ 3`~ 8 Z ~
i 'f eren rom street a ress
M_y former legal residence was in the Citv of ~~~~r.~~'"
State of ~~~.\~~~r . ~
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t
,
(No further statement 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 domicile, removal of family to new domicile, purchase of
home, etc.)
I FURTHER CERTIFY I will comply with all requirements of a legal resident of
_ this State. I understand there is a penalty for perjury;perjury is a Felony
and is punishable by incaration in the State Department of Corrections.
: ~O`~ ~C ~ O '~`n~°7 ~~i~
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PRINT NAME SIGNATURE
! ~RINT NAME SIGNATURE
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~ Sworn to and subscribed before me this _ day of a~1ir.~t , 19_~~
~ DObIGj~AS DIXON CLERK CIRCUIT COURT
~ r~'', ~ uty Clerk ~
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= RECORDINC INFORMATION ~
~ +Iotary Publ'~c,, --State of ? MAR 1
~ ' ' ' 0 Pl2 :00
~ ~ty.,-~G~rnmiss'ion expires: ~
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s ;seal) ~
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811928
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