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Rec Fw i~SG~. DOUdLAB DI7CON ~
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Doc Tas i.,.~~ t~ek at Circuit u:t ;
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DECLARATION OF DOMICILE
STATE OF FLORIDA ~
COUNTY OF S;. LUCI£ ~
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 v J u} D ( T~M F i y~ l
~9 N~A ~~,ty1,~Z. ~
(please print your na~learly)
became a bona f~de resident of the State of Florida on ,
19,~~ and I reside at ,
in the City of _Fv~-,~ F~ JC~~yid.4 .
My mailing address is : ~/D Gilr~ ~s uf FZ'
~~~~~~4• 3Y~~R ~
(if different from street address)
My former legal residence was.in the City of u,~~~ ,
State of ~~~Xe ~q M E X Irn • ~
(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. ) 1022150 .
'90 JAi~' 30 A 8 :50
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I FURTHER CERTIE'Y that I will comply with all requirements ~ ~
of a legal resident of this State. I understand there -is a
penalty. for perjiiry; perjury-is a felony and is punishable by ~
; incarceration in the State Department of Corrections.
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• PRINT NAME SIGNATURE ~ ~
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PRINT NAME NATORE . ;
~ Swor to and subscribed before me this ~ day o ,
F 19~~ ~
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DOUGLA DIXON, CL K OF CIRCUIT COURT GOUIUj
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BY ' ~ ~7~ .
eputy Clerk - vti ~ y .
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~ NOTARY PUBLIC,'State~of
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. MY COMMISSION EXPIRES: , .
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. goaK 675 P~E 94~ ~
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