S-77 form from 1992

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The following form was given to me for my library in year 1992[1-2]:

(click image to enlarge)

(click image to enlarge)

Marvin Shilmer
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References:

1. For more detail on this see: S-77 and S-79 Disfellowshipping and Disassociation forms

2. An earlier 1987 edition of this document is available in Grafmyer v Watchtower, Circuit Court of the State of Oregon, County of Marion, 2006.