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STATE OF FLORIDA 1 210 5.
G~UNTY OF ST. LUCIE ~
This is my Decl.eration Docaicile in tha State of Floritle Lhat I am filing th
day in accordence and in.conformity vith SECTION 222.17; Floridu Statutes.
~J ~'L ~ _ ; 'n ~ ~ ~ ' ; % ) _
I,(We),~ ~ r Qese rr n~your name c ear y)
became ~ a bona fide resident of the State oF Florida on ~--~%ti--
d .~~.__._~19 ~
-and I reside at ? i > ~ 'r-~l~r '
~ in the Ci ty of Pn:~ T`~ i L- L~ '3~ ~ c.:z .
My mailing address is: ~
i dff eren rom street s dres~s
My former Iegal residence was in the City of N~ 1~ ~ Y C~R U~ t=fYS
State of (y c~u ~~~r'i: • ~
(No further statement is required. However, i£ you wish, you may insert any
pertinent facts such_as sale of property or business or relinquishment of
employm~nt at tormer domicile, removal of family to new domicile, purchase oE
home, etc.) . ~
I .
E
I FURTHER CERTIFY I will comgly aith all requirements of a legal resident ~
this State. I understa~d there is a penalty for perjury;perjury is a Felony
~ and~is punishable by inceretion in the State Department of Corrections.
J ~
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PRINT NAME ~ SxG ATURE
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PRiNT NArf~ ~ SiGtJATURE .
Sworn to and subscribed -bafore me this ___{~_day of l~~ ~ , 19~
DOUGLAS DIXON, CLERK CIRCUIT COURT ~
By :t~
`.:~p. , e , .
~ ' ~ - - ~
RCCORDING INFORMATION
~+ot~ :~siic; ~ sta~e
~ 10 2 210 5
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~ '90 JAN 29 P 3 :5Z ~
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