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STATE OF FLORIDA 1021z07 ~
• COUNTY OF ST. LUCIE '
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This is my Dec~aration Domicile in the State of Florida that I am filing thi
day in accordance and in.confoi'miLy with SECTION 222.I7; Florida Statutes.
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I~~le~' p ease pr nt~ your name c ear y ;
became ~a bona fide resident of Lhe State oF Flori a on 1'9 ~
~and I reside at ~n
i~ the Cf Ly of 6_ `1
My mailing address is: ~
i f eren rom s reet e ress
, '
My former egal resid nce va~i~ the City of
, ~
State of ~ t~ •
.
(No further st8tement is required. I~owaver, if you wish, you may i~sert any
pertinent facts such.as sele of property or busittess ot relinqu~shment of
employment aC former domfcile, removal af family to new domicile, purchase aE
home, 'etc. ) , ~
I FURTHER CERTIFY Y will comply with all requirements of a legal resident of
this State. I understand there is a penalty for perjury;per~ury is a Felony
and~is punishable by incaration in the StaCe Department of Corrections.
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PRIN NAME SIGNATURE
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PRINT NAME • SIGNATURE .
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~ Sworn to nd subscri~ed before me this _,~2~ ,day of ~ ~ , 19~
~ D LAS I' CIRCUIT COU1tT
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~ epu y er - `
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~ RECORDING INFORMATION
~ lotary Publfc, State of IOZIZQ7
e yy Co~mission expires: ~ ~ '90 JAN 24 P3 ~36 ~
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~ • Fl~~i.~ :~'~C kEC~K~.
~ i DOUGLAS 01XON ~i.:
~ ~ • ~ ~ S1 IUCt= ~:Ot1NTY: ~
~ ( seal) R« F~~ s_ uu~,c:.ns u~xu~~
~ na~i r~t s _ .
St. Lucie c~unty
~ l~''y~, D~~c TaY 3___ Clerk of Circuii ~C `/ri
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~ L E COIIM'1"~
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~ BOOK ~7~ PAGE~OU4
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