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HomeMy WebLinkAbout0947 ~ , ' f • ' - ~ . . . ; _ . t .M~~ ~ . iNSfRUCT10N5 . ~ pIfASE hPE Ail~~MiFORMAt1bH; ~~1d tyn rri(1i pa~ pp~i pN~ $qn~iuh mutl W Mq~ph '"f~l~np"OIIKN CopNS . + . ? Com~ti FiNrip 01NeM 1a N~ xMOvN 6r ~OONWnr rnlwTqbn 1,,' ~ . 1 ' ~ - , • . ' . „ ' ~ STxTE bF FI~O IDA - semtaole Fotu?~~fZ~'~C 1 ~ ~ s ~ . _ . . . , TR v_ - ~ UI~IFQiiM CO M CiAI,~C`~~~~ FlNI1NCIN(~ ATEMEKT F~qM;~1CC~ ~EV:'~1~9$1 x'~`MIS'~INAN~~~EMEN~F ts~ assen~ed ~bY~ ~~iT ~frirc~ ~~liit ~~purauant 1b the ~JnUo~n Cbnwnwc~al ~Gds: • OE6TOR 1t 1 Nam~ G 1 i PN~qy . tH?S SPA~E ~by1~ b"~'~YLtN~`6~FI~Ep kA~{E 4, ~ a~~ - • ~R~t't'~~'~ `~~VIl~~1~CI' Ii~. ~ ~ O~H..TMM,HumWt'~~N(~01~ r ~ ,A , " - ' _ -~'~~~`~L~ . M~Ulll~~i A~IO(iE55 , . ~ m, . 1 ~'~1 r-1~~'t1;~"Ci`ti L~~te ~ . , ~ . . k ~ . ~ _ ~ - - ; ~ ~ . ~ CITY~t. ~~@ $TATE°~~a ~ `'3rl~~k2 . , - - " _ . . . m liAUITiPC~ OEBT R , 'pF ANY~ "(Ca31 N~m~ F~rsl~Wrson! ' ~ . - . W NAME ~R-~':~~''N, M~~fi~"I~~ ,w, . ~ ~ 0-'AtVQ~R ~,xtIRD~C ~ 1e ' fll ~'~~~V ~t:ERK ° ~ ~ - ' z MMltNB AOUp~SS L~'~e i ~1 ~~1 ~1~~~`tW7S'~`zl.`' . , ~ COUhT Y. f't.. ~ z . . . z C1TY~7t;.~~Y~~Y'CE,' $T11tEX~1S~. ~'ayo2 ' ~~JI~rV . I . _ . _ _ _ , ; ~ ~ I MULTIPIE_~TOR pF ANY? (Lait Nsme K~st i1 ~ Pe~s4nT . i NAw1E • . , 1C ' , • - ' ~ tAAYI'1~i(3 AODRESS ' I - i ' , i • GTv _ . ST~TE ~ • ' ~ SECIIR~ P~~f1l'(la Nsma iust i1 i° . _ _ _ - • . _ _ . QN1Wlf ~ . . ~ . . . - ~ ~ ~ . H~~E:ti:g~'i'~t~~'t B~flk ~~f ~~t~~t`i3t y'G~d~~t`"ty -~A ' 2A - M~~~,ka ~~pEU r .YO . ~ ~~~x " 9~0 ~ ~ ~ ~ ~ ~ ~ ~ sr~t~tl~;;l.~ . ~`4 j~~~5 _ 90~.7 c~rr ~`~t~ ~t ~ ~ . _ . MIRTIAt~ ~ECUNE~ PAhfY ~F ANY~ (1~f1 Nam~ Fust (a ~Nlon) _ NAME, . 2B . - MAtl1N(i A~DRfSS AUD~i UOD~TE G~V . $TATE _ _ . . _ . AS$IQNEE O~ SECURE~ PAATY pF AM1Y1 fL~fi N~m6 fu~t.t a Ot~fOM VAL10ATqM1 1t~IFOpMATpN , NAME _ . 3 - _ ~ . M~~~tNb'LOOAf55 .1 . . i a~ StatE , 4. teit;`~'fNANC~Nd"~~7itENEtvi eo.as ~M eoaor~rq r~pA a~e~+res dt a~r ~~Wa eeae.~p~~n er reN wop~r~r 8e ,?nxn rcc~r~a • - MO owaM 0/ rKOtO w~M ~p~wfd?11 maf ~O~Ci 1~ rWw~~O OIIKfi Wddai+ll fh~tlf !/i' ~i ~1 ` ' - =1~W 1~'~'8. ~~~11~i~~`r ~'8~t :I~i~~~i i`~'~~C~~~~~~t~~J~'~`8 . W e t~itg ' ~ 1 ~ S ~N~'~ ~0~ ~ ~~`~`l ~l a N~~'" ~ ~ - . . A 1 t T~~~~~i~~~ `~~N~4'$'~° ~ ~~~~"~'`9~I~ ~ , . , .I~~`!`f~i~ifi~ ~ a l.~l ~C_~~~~ + ~~ar~`i'~~ a~d ~ ~i ~ ~~~}i~~t~#1t°s ~~~i~~~fi , ~~1 ~~y ° ~ - - ~ ` '`~~~f~'~°it°~e, °m~ti~ '~t~~}t~~~~`f . ~ a _ . _ _ _ ~ - v~ 5: ' WocNds o1 cW+au~N u~ co.srW N p~o.+ds~ in S~ct+oris eM td~ ~~+d !t9 S Ho ot~:t:a~at SnN» p.a~~nt~d S:JJ _ - 8!_~ Fwre w~m ~t . ' L~t~.ie ..'~.b{~'~"y .~x~~k-:'~`f '~i~`±~Ci`~.ht:~ ~~t~~t , , _ _ _ _ ~ . ~ 8. ICMCI~ f,}1 ~~(AM dOtWtwM~ry fW+~p tI~N QuW W+d Wf~Gt <M 16 biKOme Ou! ~+M NrsM! DuiSU!-1! to Settro~ ~1 F S. l+ar! OM~+ D!d ~ Z_ ' Pb~Aa1 dotvrMnN(y StM~p ~~iY! /~3l~t~punb - t p~ _ _ _ . _ . . _ _ _ - _ _ _ _ _ _ . . _ _ . _ . ' ~ 9. t+rs ~vlrrr~~~ N?~~d wanov! dwfor~ sp~atu?e 10 oat~tl~ s~Euntj ~nf~n?~ ~n ca+aus~ ~C~~cr :.~r sa =~b. ICMe~ so1 - ~ ~ ' ~ " ` ~ • , .~J ~ayd~l luoj~l (6 ~ ~~cun~y ~anf1 te aRO~Mr w,~~dicaon Nn~e ~t «it aoupnt ~na lnt9 ii~t~ a e~CICN's 4: Owtw ~a i i~anam~tt~nq u~~~~tr ~ r+r btNAn tAYpW l01!~ y1N~ . ~i .r - n•oauc~f M eoeia~a~ si~ cwsr~e ~ [3 virMC~ i! ?tOtNdt 61 tM brly~nN CoN~tN~~ WftnpW ~pois N~ w/~Kh'y fKw~M/ .nr~r~f! w~! W:?KtW • - _ _ . CS N i0 wnKh IM blw~q Mf 4pl~d - . . - iURE~$?10~'DEd U'.1 ~ca+w~0 ~tii+'i'"tnanq~ b~ ~nw. w~nuiy. a capaat~ sw,cr~n ei ~n~ ~ ~,:Q ~ ~ ~ 4 ` _ . ~ r, , f ~ MWae~ C1 s~cwW ovtl- . • - - . _ . - ' 13: ' n.twn coor, ~o _ . _ _ . _ . _ - . _ . . - . t ~r if~`~°1~i'`L~:~r `I~i~~i~- W~~~d~i~~' ~~F Hiu~lE . . , rt. ~ _ . ~NAfUd~I$I~ ~EhUHEO , E~A~~E rA~. cnr . . . f _ ~ ~ : ~f Xtii.~t a. L , . s~r~ racaoE C3 f~ L ~ ' t., . Li~~~R;'A~.~~?~P. fiIING 0~~(CER COPY 3fiAN01lpG'~`b~IGA -`R'`(~~141 UC(:-1 ~ ~po•w~e6rS~e.~t.noistata.st.r~orsa.~a .~~"""'-~^'~.'t'~!*!'~.'t_"~!'~!!!$~rt~T~ ~ . _.,,.q . _ ; i