HomeMy WebLinkAbout0967 DBCLARATION OF DOMYCILB t~61233
STATS OF FLORIDl~?
COUNTY OF ST. LUCIR • -
Th3s is my Declaratlron of DomiGUe 3n the St~tbe taf F7nr~da? that I tim
€i13ng th'L8 d~?y 3n eo~osd~noe ar?d 3n confaxmitp with SSCTION 222.17
Fln~ida Statubes. •
x. ( ~e? _ • ~~~~~H ~V ~ ~jd
- {pleas~ print your name clearly)
- became a b«~a r3.ae r~,ae~t af the stabe aE FaorLde an ~ 198 7
and I resi,ae at ~ ~
~ in the CitY ~ o a? T' ~S L" f~ 9 83
My mailing address is=
(if different ~+nm stseet addressj
My former legal reaidenoe Was 3n the City . af ~v~'~v~ G~c 7'~
Stabe cf ~i~
¢K , .
~ (No furt~lier stat,ement is requfned. However, 3f you ~ish, yott may
. ~nseYt ~y pertir~ent facts such as sa]e af pmp~tty ar .bua~r~ess
or rel~izlquishmei~t af employme~t at fozmerr dom~ci]e, ~nemoval aE -
f.auni3.y t~o ne~r domi+cile, purc2~sse af home, ebc.t) -
_ ~~C~~L''/~ ~~Awc OM ~j'~ir ~oV`G ~D~~L',~.~_ _
I FURTHER CERTIFY I will v~mply ~ith ait reyuiit~ement+s af
~ a legal. ~nes3de=?t cf. this Statee I-uadar~tand -#he=e .is a p.enalty- -
~ P~J~Ys -~P~J~Y a- Felnny aad is punist~ablg _ by i;ncaral~aa
in the ~ Sta~e ~ Depaifime~t af Car~r~ect3ac~s: ~ ~
.~a~t~ff tT~LG o " _
PRINT NAMS GNATURE .
. PRINT NX1M8 SIGNATURE
Sao~n_~;,~D ,:~nd subs4r3bed bcfo3ctia me this =~day af ~lt~ , i9 g~.
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NOTARY PUBLYC, STATB ~ -
MY COI~lNIS~IQN EXP~RFS: ~8T ~C "'I P Z~4Z
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