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~'I'J?7'L OF FLOltIDA
COUN`I'Y UF ST. LUCIE
This is my [k~laratiDn of Domicile in the St~3te of 1•'lprid~ that 1~~m
fil.ing this day in accordance ~nd in c~nformity with S~:CTIUN 222.17
Flnrida Statutes.
I• (W~) _ ?~v_~~~_~~~a~_~_1s~C~Q~..~----- _ ~ _
(plc~sc print your n~~me clc~~rly)
t~ec~me a bona fide residc:nt of thc St~~te of r']nri~3a on _ 19~%~,
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and I rnsidc at J `~l Sa.:'~S ~ I~t~_--- -
in the City af~- ___S} __l..~S~ L~--. ~ J
My m~~iling ~iddrrss is; - ~L~1?'1~ - - - - - _
( if d.i.ffcr~:nt frvm strr.ct ~dd~~ss ~
My former 1L.~a1 residenoe was in the City c~f -
JtJtC Of_. _ ~i l) 1 _
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( Nc further statemerit is requir~ed. However, if yo~: A~ish, you mt~y
insert any pe.rtir~ent facts such ~-is ::ale of pr~perty or businc~ .s
or reiinquisllmc~t af emplflymc~nt at former domieilc~, r~mov~l of
~~7m11Y ~n fl.''Sd c3ntll~~~~', =t~rrfi~c~a L~ F2::.^:2^, L~1C. }
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~ I f'U:z`PfiF.R CERTIFY I will ~aomply with all zr.c;uirc~nc~ls clf
a lcgal m~ident of this `,t,~te. I unc3cr~t~rid there i~ a pcn~~lty
foz' pcrjury; perjury i;~ a Fclr~ny ~r~ci i:~ puni :}1r3hJL' t~y u~c<~r~~i ir;n
~ in the ~t.~ie Dcp::utm~~ni of C~r:-ect_i:~n~~.
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i'itI1JT NAME SIGNATURE
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i'i::i~T N11ME SiCNl1'1'URE
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:'w;~rn lo ~r,d ~,t:bscribcd bc~f~rc ?nc triis l6 c3~.y <~f .r.~ , 1~3F~
UrJUGL S DIXON, C RK CIRCUIT C TG~~1j~rjy
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Deputy Clerk • ' ~ ~
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-~o t.s69
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,v~~rnEZY pu~isc~ -s~rn~r~ af _ N~i 16 P3 ~38
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