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STATE OF FLOR IDA Z 0 2 21 Q 4.
~ • COUNTY OF ST. Lt?CIE ~ ' '
This is my DeclBration DomiciZe in Lhe State of Florid~ that I em fi~ing I
day in accordance and in.confo~ity vith SECTION 222.1~; Florida Statuees.
I~~WE~~ ~ 3C.;
p ease pr n~your ~ame c ear y
became~a bona fide residen~ o~ the State of Florida on_ ig ~
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• a nd I re s i de 8 t ! 1,~' ~
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~ in the Ci ty of ,~i % ~S 7" t_ ~ G / C ~ ~ 4r ~ ~S' 3
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My maili~g address ~s: ~
i d,~£ eren rom stree~ a ress
r1y former Iegal residence tras in the City of ,/i'~% ~ r'~t.~
State of /V t }ti: ti' ~~h~ . ~ .
(No further sL~temenL'•is required. However, f~ you wish, you may insert an;
pereinent facts such.as sale of properey or business or relinquishment of
employment at former domfcile, reraoval oF family to new domicile, purchase ol
home, etc.) ~ ,
' I FURTHER CEI~TIFY I~ill comply with aIl reqvirements of a legal resident •
thfs State. I understancl there is a penalty for perjury;perjury is a Felony
and~is punishabie by fnceratfon in the State DepartmenC oE Correct£ons.
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P:tINT NAhfE ~ S~GNATURE CJ ~
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PRINT NAriE SIGNATUBE .
Sworn to and subscribed ~before me thfs .~day of ; , 19 ~1 p
~AUG- DI N, CIRCUIT COURT
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RtCORQING INFORMATION
;~otazy Public, state of ~ ~ ~ ' ^ ~ ~ j 0
r~~y cc~„isszori ~pires: ~~',`r , 2 2 I 0 4
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