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DECLARATION OF' DOMICILE
STATE OF FLORIDA
COUNTY OF ST. LUCIE
This is my Declaration of Domicile in the State of Florida
that I am filing this day in accordance and in conformity with
SECTION 222.17, Florida Statutes.
I, ( We ? ~~1 AR c~1 ~/~~9/Ir /v~2 ,Q,~ f c p-tc.t ~y..i r'T- ~.e~ie-
(please print your name c~early)
became a bona fide resident of the State of Florida on ~ cr-~~
19~ and I reside at ~73Yv ~ESE.e?~ ~'R~EK ~e•~~ ,
in ~he City of ~,r~r -c«~~ FL ~ 3y~l~~ •
.
My mailing address is: •
(if different from street address)
Mv F~rmeas. 1....~.1 `t- ~
s~ sva.saa~..a ic~ajal LGSiI.iCiiC:~ Wd5 ~~1 LCiL ~.~.Ly dt //~//C/'/'~'~. •
State of ~'~N,~d •
(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. ) 'y~ ~ar.; ' ~
1021738 ~ BE~
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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
f
~ penalty. for perjury; perjury is a felony and is punishable by
~ : incarceration in the State Department of Corrections.
~ ~~l AR t,E S ~D~ w 9~/" 2r/L- .u_ ~r~
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~ PRINT NAME SIGNATURE
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6 PRI T NAME NAT E
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~ Sworn to and subscribed before me this~~ day of ~ .
~ ~ g.,Ly ~ ~ 0 U~l
~ pOUGLAS DIXON, CLERK CIRCUIT COURT "'~:E~*..
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BY ~ c v~'~ v s ~ ~~i
ty Clerk .~:T t
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NOTARY PU~LIC,~State~of
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~ MY CQMMISSION EXPIRES:
~
~ BO~O~I V l5 PA~GE 2~~
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