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TtllS STATEMENT is preseaNd b a filly effiosr for filip persr,al b the llwiferw Cenwerciat Cedar 9. MaMrity doN (if ar?c
1 . Cobtei (i) Ilost tjbwe First) an/ oddress{es) Secrrsd torelrlin? oed eddressles? ~ Fer filip Officer (DeM, Tiw,, lCcwber, aed RBy Gffip?
GEORGE S. FOX, JR., O.D.S. ,PA PORT ST. LUCIE BANK
9507 S Federal Hwy, Suite 2 900 E, Prima Vista Blvd ~s'.1.4~
Port St. Lucie, FL 33452 Porti St. Lucie, FL 33452 .
~ Tbtt ttetewent fen i f- twe 412002 -
filed wab C~er~C o`~ C~rcu°~~°`iC'O ~r~~-Nd August 2, 1978
5. ~Ceefis.afiee. • The eri,iaal 6soecia, sto»_ese,t Mtweow the fere,oip D,Mer end Settmd ?ory. Morin, fiN arwMr sAewa oboe, is still effecti.e.
6. ? T,ti.6saciM. Setered twrh. ao toe,er cloiws o severity ~abrsst ,ader Ma fiaoaap sbNwea! Moriny fiN acwber sMoirn oMvt.
7. Q Assi~. TM second porer's ri,At radar the fiweacip sfoNweet Moray fiN aewMr sbo.n oM.e b tM poaeM described iw Ifew 11 ies boon ossifswd
b IM essi,eee wbwe wosN end oddnss oppeer is INw I1. -
6. [xArassdw,at. Fiemiciy SbNeieat beorip fiN swwbor shwa obere is aweswled os sN forflr is INw 11.
9. ? ftelerwe. Sscrnd ?artr rtNeses the wlloterol deur:bed is Itew 11 "frow tM fiaoaciy stotewewt Morip fiN acwber sAOwn eMre.
l0.[xC>teck If tree. -All decrwwtNry stewp tales doe oad perobM K to becswe doe end peyeble persreat ro CbepNr 201, f. S. b.e Mew poid. -
I1.
See schedule "A" attached hereto and by this reference made a part hereof.
lf.. of additional sheets presewted: 1
GEORGE S. FOX, JR.,:D.O.S., P.A. PORT .LUCIE BANK
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