HomeMy WebLinkAbout0970 . . ~rcusrri~an ~iz ~o~nu~,c ~
STATB OF FLORI~A 8 j82(~8
• COUNT'Y OF ST. LUCxE . • •
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This ~s my Decleratio~ Oomf.cile ~r~ the State of F~orida Lhat I am filing thi
day in accordance and ~n.conFoicmixy ~rith SECTION 222.17; Florida Statutes.
I ~ ~ ~e ~ ~ ~ 1NC4 ~/V .
. p eeee pr n•your ~ame c ear y.
. becam~ ~e bona fide~resident of ~he State oF Florida on 1'g 8~
•and I res~de a~ l0 7 y S~ ~U. ~O~Uc~'O,~i~9'/~ ~
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fn tlhe City of _/~R9'' i• ,~~c~~ . t~~o~iD~! ~4~~53
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My mailing addrsss is: ~
f eren rom s reet e ress
My former legel residence was in the City o~ B!G L~k'~ ~
State of ~¢L/~sX/9 .
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(No further statemetnt is required. Ejowever! ig you wish, you may insert any
pertinent facts such.aa sale oF property or business or relinqufshment of
employmenC at former doanicile, temoval of family to new domicil.e, purchase of
home, etc.) .
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~ I FURTHER CERTIFY I vill comply with a21 requirements of a legal resident o: ~
this State. I understand Lhere is~a penalty for per3ury;perjury i.s a Felony
~ and'is punishable by incaretion fn the State Department oE Correctio~s.
~N co/N
~2d 8 G. '
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~ PRINT NAME ~ SIGNATURE
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PRINT NAME SIGNATUItE
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~ Sworn to and subscrf~ed bsfore this ~day of CG~~ , 19
f DOU DxX ~ CLERK ~ ~:C
~ BY ~ ~~:~Fr~-..,.C~,~ T
~t
i e uty er ~
v `4 ~ .
~ RCCORDING INFORMATION
Notary Public, State of__ '~fcou~,,' .
`fy Cor~mission expires: ss~ti48
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• ' ? '87 NOV 12 P 2 :42
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