ACKNOWLEDGEMENT AND ACCEPTANCE FORM $115571-01
ACKNOWLEDGMENT AND ACCEPTANCE FORM
REGARDING THE PETER E. FIELD CREDIT SHELTER TRUST (THE "TRUST")
I, CITY OF CLEARWATER, as beneficiary of the Trust, hereby consent to the
disbursement of the sum of ONE HUNDRED FIFTEEN THOUSAND FIVE HUNDRED
SEVENTY-ONE AND 01/100 DOLLARS ($115,571.01), (the "Gift") as full payment of
the amounts due to me under the terms and conditions of the Trust. I hereby instruct
O'Connor & Associates to disburse this gift to me at the following address:
Margie Simmons
Finance Director
Finance/Finance Operations
Municipal Services Building
100 South Myrtle
Clearwater, Florida 33756
I hereby release and hold harmless the Trustee, Barbara Dorian, from any and all
liability, claims, causes of action or such other matter which I may have in the past,
present or future. @
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IN WITNESS WHEREOF, I set my seal as of ~ 7 " 2002.
Countersigned:
LEARWATER, FLORIDA
~
illiam B, Horne"
City Manager
Approved as to form:
Attest:
-~~
'a E. Goudeau
erk
STATE OF FLORIDA )
COUNTY OF PINELLAS )
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\, The foregoing instrument was acknowledged before me this f day of
J '"\LA.-O ' 2002, by BRIAN J. AUNGST, Mayor-Commissioner of the City of
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Clearwater, who is personally known to me.
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PrintlType Name:
Notary Public
NOTAAV ",U8UC. tt'fArE OF FLORIDA
CAROL 'iN l BRINK
Co.\tMISSION II CC834678
EXPIRES 512212003
SONDED THRU ASA 1-88S-NOTARYl
STATE OF FLORIDA )
COUNTY OF PINELLAS )
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-', The foregoing instrument was acknowledged before me this t; '-' day of
YV'LC'-"-' , ' 2002, by WILLIAM B. HORNE II, City Manager of the City of
Clearwater; who is personally known to me.
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PrintlType Name:
Notary Public
NOTARY PUBLIC. STATE OF FLORlOA
CAROLYN L BRINK
COMMISSION II CC834678
EXPIRES 5/2212003
OONOr:O THR~I .".;lA 1-88B-NOTARY1