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DECLARATION OF DOMICILE
STATE OF FLORIDA • )
COUNTY OF S 1' < ~~~g )
This is my Declaration of Domicile in the State of Florida
that I am filing this day in accordance and in conformiCy with
Florida Statute Section 222.17. ~
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1( we lv I l C l/~/y ~ • /~S T/~r' L~" S!L .
print n~me c ear y
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became a bona fide resident of the State of Florida on _.__6f.,~0 ~'i
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and I(we) reside at I'Qf Q~"~"~~~/QN , j
in the Ci ty of _ p0~ ~ I T L ~G County of -r7. L dG/ j*
My (Our) mailing address is: S~~'' 3~ly~'.3
My (Our) former legal residence was in the City of ~"''d~~j'~-
S t a t e o f_ /V tr'~- y D/l~,/
.
(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.)
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I FURTHER CERTIFY I(we) 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 incarceration in
the State Department of Corrections. ; ~
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~ Sworn to and subscribed befor me
this ~_day of 9
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; Notary ~~ub c--o~ o~ r icia ing " ,
; Acknowl edg~rien t `s~- _ 84592~
My~or~o~mi.,~~~~'on. ~pires : L'~ _ ~ .
F ~-ry. ~bti~~~~j~~k/e At (ar
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f - "..~',n:,f.,P ~h120, 1989
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600K 5~6 PACE ti7~1
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