HomeMy WebLinkAbout0968 ~e~t~rrli~n af ~omicii~
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STATE OF FLORIDA ~i~
~ • COUiVTY OF ST. LUCIE . ' ~
This is my Declaratio~ Domicile in the Stete of Florida that I am filf~g thi
day in accordance and in.conforminy vi'th SECTION 222.17, Florida Statutes.
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I~(Ne)~ ~ f~~'iv I`• rAJN.t ~
p sase pr n your name c ear y •
became ~ a bona fide reaident ol the Siete~~of Floride O[1 ~ 1~ ~ f 1g j
~and I reside at ~ ~1 ~ Z- ~~'E" ` ~
~ in tha City oF I~~~y-~ ~ `~i~ `I
My mailing addresffi is: '
eren rom s ree a ress
My forcrer legal residence was in the City of ~ r^~ f"-t
State of ~`(:~1! • ~
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(No further stateaas~t is required. ~owever, i.f you Wish, you may fnsert any ~
pertinent facts such as sele of praperty or business or relinquishment of
employment at forcaer domicile, removal of family to new domicile, purchase of
home, etc.) •
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I FIIRTHER CERTIFY I will comply vith 821 requirem~nts of a legal resident oi~
~ this State. I understand there is a penalty for per~ury;perjury is a Felony~ ~
~ and~is punishabZe by incaration fn the State Department of Corrections.
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~ PRIfvT NAME ~ SZGNATURE ~ ~
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~ PRI!~T NAME • SIGNATURE
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~ Sworn co and -subscri~ed before me this '~_dey of , 19-~~~ ~
~ DOUGjr:AS DIX~~ ~ CI&CUIT COURT " ~
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- Deputy er ~
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~ ,~;,~;;,~,~,,;,,y~ RECORD~NG INFORMATION
~ tiotary Pu~I1C, S~~tte Of = ' - ~
Hy Co;ry~ni ~ s f on expires s ~ - i~~` ~i~
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