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STATE OF FLORIDA ~2"~'4a?O . -
• COUNTY OF ST~ LUCIE • • ~
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This is my Declaration Domfcile in the State of Florida that I am filing thi
day in accordancQ and in.conformi.ty wiCh SECTION 222. 7, Florida Statutes.
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I, (We), ~ ~ Q1~ , GOS ~ ~'1 i
p ease pr~.nG your name c~ar y !
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. became ~a bona fide resident of the St te o Flori.da on_ ,~~~7 ~9 '
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•a~d I reside at ~a0 ~ C U e.. ~1?', : j
~ in the City of V G 33 Sr
My mailing addr~ss is: l~1'?~
~ (iE d~f eren rom street a ress
My fo:mer legal residence was in the City of_ S/~D^,S~S~ T f
State of ~etv y . ~
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(No further statement is required. However, if you wish, you may insert any ~
pertinent facts suct~. as sale oE property or business or relinquishment of
employment at former domicile, removal of family to new domicile, purchase of
home, etc.) ~ . ~
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' I FURTHER CERTIFY I will comply with all requirements of a legal resident o
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~ this State. I understand there ~s a penal.ty for perjury;perjury is a Felony
s and~is punishable by incaration in the State Dep tment of Corrections. "
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PRINT NAME ~ SIGNATURE
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~ ~~C~ h~l ~'1 A~- C70 n l.C .
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PRINT NAME SIGNATURE
Sworn to and subscribed before me this /v~ day of oc.,c.,c.~ , 19 ~7
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. " DOUGLAS , CLERK CI. xD
~ By ~ , r. cG
Deput erk 4+`~4,~!)
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a `''~~'-•~`'s"`~'~=`~•~ RCCORDING INFORMATION
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: ~otary Public, State of `'<<~L:~:~.t~~t`~`
` 82'741U
: ~1y Commission expires: • , ;
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; ~ ~ '87~ ~ '1 P ~ ~
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~ (seal) FILED aND ~Z~~ORDEO ~
~ ~ OOUG~~?5 UIXON CLERK j
E ST, L CIE COUNTY. ~L.
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