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DECLARATION OF DC~MICILE
STATE OF FLORIDA
(`Qf1NTY C1F GT ; T.il(`T F`
This is my Declaration of DomiGile in~the State of Florida
that I am filing this day in accordance and in con£ormity with .
SECTION 222.17, Florida Statutes.
I, tWe)_ ~~c~cL ~ ~~fiY1G~ C~ ~
(please print your name clearly)
became a bona fide resident of the State of F'lorida on ,
19~ and I reside at 'aJ ~ ?
in the City of _ ~ C~' - •
My mailing address is: •
{if different Erom street address)
My former legal residence was in the City of _?~i~/~7! 12/.4c~/~%a~' .
State of N~ j - •
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~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.),
~o ~aN 26 a~ ~ :5+'
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I' FURTHER CERTIFY that I will comply with all requirements
~ of a legal resident of this State. I understand there ~is a
j penalty. for perjury; perjury is a felony and is punishable by
~ incarceration in the State Department of Corrections.
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~ . PRINT NAME SIGNA URE
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~ PRINT NAME SIGNATURE
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Sworn to and subscribed before me this ~G da c~, ,
a 19~. ~ vOU~,jT~;• ,
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~ DOUGLAS DIXON, CLERK OF CIRCUIT COLRT `
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BY ,,;:'~.,~_~y, _
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D put Clerk `'",~F ~ ~
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NOTARY PUBLIC,'State~of
MY COMI~iISSION EXPIRES:
fio~ s75 P~~E 1fs
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