HomeMy WebLinkAbout0974 DfiCLARATYON OF DOMICILB /
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~s2~4s
STATS OF FLORIDA
COUNTY OF ST. I.UCYB
This is my Declaratinn a~ Domic~le 3n tt~e Stabe a~ Flasida that I acn
filing this day in aooordanoe and 3n oonformity with SBCTION 222.17
F'lnrida Statut;es.
I. ( F1e) ~1- / C
(please pr nt your ~ame clearly)
became a ba~a fi,de re.gi,dent aE the Stabe af Flniida~ rn~ 19~
and I xeside at A-~/ ~ p4
~ in the Cixy ~
My mailing address is;
~ t if differez~t frvm street addx~ss )
My form~r ]~egal residenve was in ~ the City a~ _~~,~r~ 6` a~- ~~,~,-r-a ti/
State o~ ~ ~ .
( No further stabement is requ3red. However, if yw W~sh, yvu may
insert any pertinent facts such as sale a~ property ar btxs3ness
or rel.inquishmc~t a~ emplnyment at ~orme= domi,cile, removal af
family fa~ new docai,cal,e, purchase af horree, et~c. )
I F[IRTHER CERTIFY I wil1 oomply with all =equix~ements dE
' a legal resi,dent aE_ this State.. .I understand thexe is a p~enalty
for p~jury;: perjury is a Felnny a~d is punishable by 3~ncarati,on
in the Stabe Depaitn~ent a~ Co=rect3nns. _
, .
PRINT AME SIGNA'
PRINT NAME SIGNATURE
Sworn fio and subscribed before n~e this /Q ~ day af ~ Z ,19~
DOUG ~ DIXON, - CLERK CIRC - _
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Deputy Clct)t . ~ ~ G ~~i,~4s
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I~I(3'TARY PUBLIC, s~rA~ ~ ~''~'~'~.~?r~`` ~ '87 ~C 10 A11 :43 ,
MY COMMLSSZOI~i EXPIR.ESs O
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' gOQK ~e74~~ PACE ~ 1 ~
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