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STATE OF FLORIDA 1021898 ~
COUNTY OF ST. LUCYE '
This is my Declsration Domicile in the Stete of Florida that I am fi~i~g tl
day in accordance end 3n.4onFoi-mity vith SECTION 222.i7; Florida Statutes~
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I , ( We ) , ' ~ , \ ` ` ~ ~ ~ ~ y ~ ; - ~ j - ~ ~ ~ ~ < ` f t~t ; ' ~ s `
"~~T~'ase pr n~ your name c ear y , ~
became~a bona f3de residenL oF the State oF Florida on 19 /
•and I reside at ~G~ J~' / ? c,~ ~f ~ ~ l~}~ .C-L:i(~ 7='
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~ in the Ci ty of ~ L~~~ ~ t~ ~i'~-~ l~_/ F
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My rnailing address isr _ J~YY1 Q r, ~
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My ~Eormer le e2 res~derce vas in tha City oF_ 1"~ i~~ ~~~r
State of j~~- ? 1''_} ' , ~ . -
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(No further statement.is required. However, if you wish, you may ins~rt any
pertinent faets such a~ eale of property or business or relinquishment of
employment at tortner domicile, removal of fac~ily to new domicile, purchase oE
home, etc.) ~ •
I FURTHER CERTIFY I vill comply with all reqr~ir~raents of a legaZ resfder~t +
thfs State. I underatend there is a penalty for perjury;perjury is a Felony
and~is punishab~e by inceration in the State Department of ~orrections.
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PRINT NAP1E SIGNATURE . _ ~
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Sworn to and subscri~ed -bafore me this -~~day of `y~i.;~.~u~ti+« 19
. DQUG~IS D~XON, , CZERK C~CUI? £OURT ~
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eputy C er ' •
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' RtCOROING INFORMATION
:votary Public, State of
hzY c«~,~s~«, r~~: - . I 0 216 9 8 .
~ ~ '90 ,1Atd 29 A11 :0~
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