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STAT~ OF FLOR IDA ~ O 2 2 916
COUNTY OF ST. LUCIE
This is my Oectaratfort Doaicile in the State of Florfda that I am filing t
day in accordance end fn.ao~ffli~iLy ~?ith 5ECTION 222.17~ Florida Stetutes.
I, (We), l L~l l~7 IL ~ S • ~i'~D ~L . .
p eas~ pr n~ your naane c e~r y
beca~e ~ a bona fide residenL of the State oF Florida on_ ~`~~19,~,~
•and I reside st J~~~ S. % ~.~'~C .
~ in the Ci ty of U r' ST", ~y c~ . ~ cI ~,3~,,..._,__
My maf Iirtg address is: '
, fser~n ram s ree $ res~
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Fty former Iegal residence was in the City oF
h~/~,~1 ~~-Q~ ~
State of N ~ r~ ~
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(No further statea,ent~is required. However, if you wish, you may insere an
pertinent facts such.as eale of property or buainess or re2l~quisha~ent of
emplayment at Pormer domicfle, removal of Eemily to new domicile, purchase o
nome, etc.) ~ .
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I FURTHER CER'TIFY Y~rill comply afth elI requirements of a iegal resident
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this State. I under8tancl tlsere ie e pena2ty for perjury;perjury is a Felony j
and'fs punishable by inceretion in the State Department of Corrections. ~
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PRINT NAME ~ SI6NATURE
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PRiNT NAr~E ~ SiGNATURE . ~
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Stiaorn to an subscribed-before ma this -~1 _day oE , 19 U ~
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DLX RCUIT COURT / ~
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isotary Public, State of ~
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