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DECLARATION OF DOMICILE
STATB OF FLORIDA '
COUNTY OF ST. LUCIE
This is my Declaration of Domicile in the State of E'lorida
that I am filing this day in accordance and in conformity with
SECTION 222.17, Florida Statutes.
I, (We)~a ~~2vinG I~oS~ 4(b ,
(please print your name clearly)
became a bona fide resident of the State of Florida on ,
19 ~ and I reside a r~ c ,
in the City of 3 y,_s~ ~
My mailing address is: ~ ~
• (if different from stre~t address)
My former legal re idence was in the City of ~~rl ,
. State of • ~ .
~No further statement is required. However, if you wish, you may
insert any pertinent facts such as sale of property or business
or relinquishment of employment at former domicile, removal of
, family to new domicile, purchase of home, etc.)
~ JAN 23 P12:42
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I FURTHER CEATIFY that I will comply with all requirements
of a legal resident of this State. I understand there ~is a
' penalty. for perjury; perjury is a felony and is punishable by
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I : incarceration in the State Department of Corrections.
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~ • PRINT NAME SIGNATURE
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~ Sworn to and subscribed before me this ~3 day of ,
~ 19 /
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DOUGLAS DI ON, CLERK OF' CIRCUIT COURT ,~"1 ..'.-~•~~.f~_•-....
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BY : ~ f~ r - ,
Deputy Clerk L':~'~A
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~ NOTARY PUBLIC,'State of
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~ MY COMMYS3ION EXPIRES:
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674 F,,~E 91? ~
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