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STATE OF FLORIDA 81.9sQ1.
~ COUNTY OF ST. LUCIE ~
~ This is my Declaration Domicile in the State aF Flori~da that I am filing this
day fn accordance and in.confoirmi~y with SECTION 222.17, Florida Statutes.
_ ~ ~
T ~ J': .
I , ~ We ) , _ • ~ = ~ 'TODl~1
' (please pr~nt your name c ear y E
t
.became~a bona fide zesident of the State of F~orida on~ ~ 19 3 ~
-and I reside at_ ~a ~~)r?2l5~ ~~V~ ?
, F~-
in the Ci ty of
My mailing address is: d Un21 i~,~YD • ~
i fferen •rom s~`reet ac~ress
My former legal residence was in the City of
State of_ ~%f~.,~n/~ .
(No £urther 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 domici3e, removal of family to new domicile, purchase of
home, etc.) ,
, _ .
I FURTHER CERTIF'Y I will comply with all requirements of a legaZ resident of
this StaCe. I understand there is a penalty for perjury;perjury is a Felony
and is punishable by incaration in the State Department of Corrections.
1 E~/~ n~" ~7~7l.c~ 1 +7 ; ~ ~l~
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PRINT NAME ~ SI6NATURE
PRINT NAME SIGNATURE
Sworn ,Eo and..subsc~ibed before me this ~j day of ~ , 19 cY'?
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~GLAS DIX~N, CL CIRCUIT COURT
By ~ - . '
Deputy C erk ~
I RECORDING INFORMAT ~
ION ,
Notary Public, Stare of ~l
' `1y Cor~mission expires: ~ J
i • ~~sso~. ~
! '87 ~S~R 21 P 1 :41 - '
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- e~oK 539 PACE 9~7
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