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[4x. Ta~t =~..~Clerk ~ it Coutt
!nt Tas = By ~.___°~d..~
_ ~ . , _ - ' ~ Deputy ~st~
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~ DECLARATION OF DOMICILE
STATE OF FLORIDA
COUNTY OF ST. LUCIE
This is my Declaration of Domicile in the State af Florida
that I am f iling this day in accordance and in conformity with ~
SECTION 222.17, Florida Statutes.
I, (We) ~ T~~ ~
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(please print your name clearly)
became a bona fxde resident of the State of Florida on rr~
19~Cj and I reside at o~ `i j,~,/~;l~~TD.~/ C_ ,
in the City of ~ - f~~ ~ 3 -~i .~s ~ .
My mailing address is: S~ /7~~ . ~
• (if different from street addr. gss)
My former legal residence was in the City of r~,(/o/~ T~T ,
State of _F~~~ ~ jJ~t . ~
tNo further statement is reguired. 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.)
;
~0 JAN 25 P :15 ~
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, . S1..~Ur.~?- cOUMfY ~
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; I' FURTHER CERTIFY that I will comply with all requirements ~ '
E of a legal resident of this State. I understand there ~is a
penalty. for perjury; perjury is a felony and is punishable by
~ : incarceration in the State Department of Corrections. .
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~ • 1~L T r" ~ I i1/6TZ/
a • PRINT NAME SIGNATUR
f . '
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~ PRINT NAME SIGNATURE
~ '
~ Sworn to and subscribed before me this~ day of ,
~ 19...L= • .
`e , b Cj~ UN~'y
• pOUGLAS DIXON, CLERK OE' CIRCUIT COURT j ~E~K CCr.~
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i BY : ~ i 'r" r t!~
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De ut Clerk
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~ NOTARY PUBLIC,'State~of
~ MY COMMIS3ION EXPIRE3:
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a 600M ~ / ~ PACF ~ fV"a~ ~
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