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DECLARATION OF DOMICILE
STATE OF FLORIDA 81~SO~
COUNTY OF ST. LUCIE
This is my Declaration of Domicile in the State of Florida that ;
I am €il~r.g ihis day in accordance and in Gonformity with Section 222.17, ;
Florida ~t~tu~te. '
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a( We ) ~ A L ~11~ - cC ~ .
(p ease pr nt your name c early)
~~w~~~Y
became a bona f ide resident of the State of Flor ida on ~ 19
and I res ide at 2'~-55 ~ w~u. c'-.n'Q~rr'-' =---~w•-
in the City of ~o,~.r S-r l.vuF F~I~ ~i3h~5~..
My mailing address is Tr~~ l~. ,4aovc
(i~i ferent rom street address)
My former legal residence was in the City of /Yq~~l ~'~rtffA~rnR-
~Ee" O f ~Mc~,y p .
(No furthsr statement is required. However, if you wish, you may
insert any pertinent facts such as sale of property or relinquishment
of employment at former domicile, removal of family to new domicile,
purchase of new domicile, purchase of home, etc.)
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I FURTHBR CERTIFY I will comply with all requirements of a legal
E resident of this State. I understand there is a penalty for perjury;
~ perjury is a Felony and is punishable by incaration in the State
Dep~ttment of CQrrections.
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~ ~W4+,.P UlI• ~c.E ~`~Irv~ ~iw
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PRINT NAME SIGNATURE
PRINT NAME SIGNATURE
S rn to and subscribed before me this ~~day _
o ,19 ~~l
~ DOUGL DIXON, C :a~ItCUIT COUR
~ ~ < -
~ ` ~DE` Q'~Y LERK
~ ` •
. ~ ~ 87 APR -3 q11:42
NOTARY PUBLIC,~: ~TATE ~OF
MY COMMISSION ~1~p~X.PS, " . . ~
DOUG ~ ~ , , ~ i; . f RK ~
s SE~?L ST.IUCIE (;+):;';;'f F-!. ~
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~ 816504
~~37 ~~8~
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