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• DECLARATION OF OOMICILE J
STATE OF FLORIDA
.
COUNTY ~F ~T. ~,~I~IE ;
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This is my Declaration of Domicile in the State of Florida that
I am filing this day in accordance and fn conformity with Section 222.17,
Florida Statu•te„
. I ~ ( We ) , SO rl ~ ~F? ~ S'f' (c' Q f'~ OL- -
(p~ease print your name clearly)
became a bona fide resident of the State of Florida on ~ 19~
and I reside at a2- So •~~12 n t?1~ ~~T
in the Citv of P+. 1..~ ~C~ ~ P, _
My mailing address is ~ olS ~-~v v~ ~
(if di ferent from street address)
My former legal residence was in the City of ~PuJ y021~
State of JVeW ~or~ •
(No furth4r 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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s I FURTHER CERTIFY I will comply with all requirements of a legal
; resident of this State. I understand there is a periaiiy i~i ~.ci~ur~;
~ perjury is a Felony and is punishable by incaration in the State
~ Oepartment of Corrections.
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PRINT NAME SIGNATURE
PRINT NAME SIGNATURE
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;:w~ t u! :~i~ l f> >1~=; . r j l~ l, : t ~ l ~ ~ ti- -~g~
o ,19 $ ~1-~ - ~ ~ . 's
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~ DOUGLA DIXON,.CI~RK=~~RCUIR COUR
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i; DEPU LERR.y% '~7 (':~i( 2~ P 1~57
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NOTARY PUBLIC, STATE OF ' .
3 MY COMMISSION expires: ~ ~ ~ ~K
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SEAL
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