HomeMy WebLinkAbout0949 ~ . . ~ . ~ett~tatiaa rf ~aii~tt i.
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STATE OF FLORIDA 8fi667S
• couN~r o~ sr. ~.uci$ , • "=~i
?his ~s my Dac~ara~ior Daaicile in the Stata ot' FloritJe he~ i em f~li~g th'i~
day i~.n accordares end in.conla~mi~y vith SECTYON 22Z.1y; F~or da Statutes. ,ti.
I , ~We~~ ~ ~ ~ ,r~-
sass pr yo »ams c r y ~
. became ' a bona f ids rssi e~n! ot the State ~ af Flori. s on
~.m~~
9~~
•and I reside et a
,
in the Ci. ty of~„ 02 ~ t. /c
My mailing ~ddross ~$s ~
, e en roai a ree a r~ss
My former legal residarce wae irt eha Gity o ~/~,~sYl..~- .
S t a t e of„ ~
.
(No further statemen!' is requ~tred. ~owever: ff you wish, you may i.nsert any
pertinent facts auch.ae.sale of proparty or businesa or relinquishment oF
employment at !`ormar daoicil'~~ removel oi~ Eamily to new dom,icile, purch~se o~
home, et~.~ ~ • •
I FUR7'I~ER CERTIFY I~ill camgly arf th a~l requirea~enta of a legal resfdent o~ :
this State. i understand there is a penalty_ for perSury;per~ury is a Feloay
and'is punfshable by incarat~on fn the Stete Depertment of Correctfons.
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PRINT NAME ~ SIGNATURE
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PRINT NAM . SIGNATURE _
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~ SWOrn to and subscrif~ed b~e~ ~this ~
day of l~~~ ,~9~
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~ DOUGLAS IXOAt, ~ ~ URT
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~ BY c>
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~ '''o ~ REC4RD~NG INFORMATION
~ yotary Public,,Stst~ o!' •
, Hy Conynissior expiress • ~ • . ~~~6~'~
. ' ` . '88 JM1-4 l~1:44
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FILEQ'ANO E; C~RQ~U
~ Q~ LAS DIX 1~ CI.ERK
~ ~ ~ ~~T, t,UCIE COUkt Y. FL.
~ 6~OK ~~O PAGE ~
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