Island Village Condominium Association

2135 N. Courtenay Parkway E140

Merritt Island, Florida 32953

AGE VERIFICATION STATEMENT

1. NAME _____________________________________________________________

2. CURRENT ADDRESS:

__________________________________________________________________

Street

__________________________________________________________________

City                                                                  State                               Zip

3. Approximate date I will be moving into Island Village Condominiums: _______________

4. Number of persons that will reside in the unit purchased at Island Village Condominiums.___________

          Note: Each resident must file an age verification statement.

5. Date of Birth_________________________

6. Proof of age must be verified by one of the following documents.

       A photocopy of the document must be attached to the statement.

                                             ______________Driver’s license

                                             ______________Birth certificate

                                             ______________Military identification card

                                             ______________Immigration card

        I declare, under penalty of perjury under the laws of the State of Florida, that the foregoing is true

        and correct of my own knowledge.

        Executed this _____day of _______________, _____, At ________________,Florida.

        Witness:                                                           Owner/Buyer:

        _______________________                         _________________________________

        Signature                                                         Signature