HomeMy WebLinkAbout0350 1 U~ 1~ U L ppUCiL.ll3 DDCAN
• Add F'~~ s,.._~__,_„_ St I.ucie Countv
~At `i'r?~ ? -l ~f Circuit Cotttt
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DECLARATION OF DOMICILE
STATE OF FLORZDA
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) `~~=i~ C i~=t ~ -
( please print your name clearly ) %~c,~ '
became a bona f ide resident of the State of Florida on ,
19 and I re s ide at % jit ,c1 / ~i ~~~'4
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in the City of y; C_'-~ _-/c'' ° t=~ % i~> t" _
My mailing address is: `%~'i i~:~~ •
(if different from street address)
Mv former leaa ] rP~i clPnr-P ~a~ ; „ n; ' ,
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State of [ / _ / I _ • v
(No 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.) ~ JAN 26 P 3~28
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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
~ penalty for perjury; perjury is a f~l~ny and is punishable by
~ ~ incarceration in the State Dep~ tment' f Corrections.
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4 • PRINT NAME S~ NF~'TURE t_ ~
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~ PRINT NAME SIGNATURE
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~ Sworn to and subscribed before me this~~~~day of Q~,
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DOUGLAS DIXON, CLERK OF CIRCUIT COURTb ~ C'..
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. BY : ~ - ~ " ~ t, `f~''b ~
De ut Clerk ' ~t
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^ev~art•
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NOTARY PUBLIC,~State of
MY COMMISSION EXPIRES:
5
~ Ba~~ 675 P~~E 350
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