HomeMy WebLinkAbout0945 DRCLnR11't'ION Of' QOMICII~F.
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869641
S'P11TE OF FLORIDA
COUN'1'Y OF ST. LUCIE
This is my Declar~tion of Dc~micile in the State af Fl~rida that I am
f.iling this day in accord~~nce and in oonformity with SECTION 222.17
I']~rida Stattites.
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(please print your name clearly) ,
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ta~L!~n~ a hnrU~ t'ide msident of the State af F]nrida on 19 ~
and I rnside at - - ~ ' - ~
z + -L~ i/ 6 G - ejs~ o o ~ ~ /R - iL 1.i_ .~'n~~.~ us ~
r he City c~ - ;
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My mailing address is; '
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( if different from street address ) ;
My former legal residenoe was in the City o~f _~z~o~~r~.
State of--~~~''~J!_~~1 Y~1?_t,~- _ `
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(No further st;atement is rc~quir.ed. However, i.f you wish, you may ~
insert any pertinent fa~ts such as sale of property or business
or relinquishment of emplDyment at fonner dornicil~, r~moval o~f ~
Family to new domici]~, pu~hase of home, etc. ) - ~
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I FURTNER CERTIFY I wi11 comply with all requirements of ;
a]egal rnsident of this State. I understand the~ is a penalty ~
for perjuxy; perjury is a Felony and is pimishab~ by incarati,on ~
in the St~te Departm~nt of Corrections _ ~
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PRINT NAME
SIGNATURE
PRINT N11ME SIGNATURE
Sworn to and subscribed before me this ~~_day of -~~_,19 ~
DOUG S D- ON, CLERK CIRCUIT COURT
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NOTARY PUBLIC, STATE acf _l__ ~~~'FC~,~r;n,F~°
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MY COMMISSION EXPIRES:
'88 JAN 21 ~11:28
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ST. LUCIF L•ei:i'f' ~
~~~K 572 PAGF 945 ~
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