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THE OAKS OF CLEARWATER -- A. SETTLEMENT ST ATEMEN'f United States Department of Housing and Urban Development OMB No. 2502-0265 -- B, Type of Loan I Loan Number Mortgage Ins. Case Number I File Number 01,08,0002 -.. C, Note: This form is furnished to give you a statement of actual settlement costs, Amounts paid to and by the settlement agent are shown, Items marked "p,o,c," were paid outside of closing, they are shown here for informational purposes and are not included in the totals, -- D. Name and Address of Borrower: E. Name and Address of Seller: City of Clearwater The Oaks of Clearwater, a not for profit Florida corporation and Baptist Estates of Florida, Inc" a not for profit FL corp, TIN: -... F. Name and Address of Lender: G, Property Location: 210 South Osceola Avenue Clearwater, FL 33756 Prop Id: 104,] DE H, Settlement Agent / Place of Settlement: I. Settlement Date: RS Scodis American Acquisition Group, Inc. Closing: 5600 W, Mariner Street, Suite 104 Disbursement: Tampa, FL 33609 TIN: ---.----- J,.sJlmm3ryQfB9rI:.9.w.~r's Tnmsacti9JL,. -_..-------- _U'_ - ----- _K.~ulllm~ry of.Stlful!,'sTra.nsa(:tion 100 Gross amount due from borrower 400 Gross amount due to seller 101 Contract sales price 20,250.00 401 Contract sales price - ------- 20,250,00 102 Personal property 402 Personal property -------~ 103 Settlement charges to borrower [1400] 403 . 104 404 105 405 Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance 106 City/town taxes / / to / / 406 City/town taxes / / to / / -- 107 County taxes / / to / / 407 County taxes / / to / / -~ 108 Assessments / / to / / 408 Assessments / / to / / ..- ---- 109 409 - 110 410 111 411 -. 112 412 -- 120 Gross Amount Due From borrower 20,250.00 420 Gross Amount Due To Seller 20,250.00 200 Amounts paid by or on behalf of borrower 500 Reductions in amount due to seller 201 Deposit or earnest money 501 Excess deposit (see instructions) 202 Principal amount of new loan(s) 502 Settlement charges to seller [1400] 203 Existing loan(s) taken subject to 503 Existing loan(s) taken subject to .-. --, 204 504 Payoff of first mortgage .. 205 505 Payoff of second mortgage ------ ~. 506 Deposit retained by 207 507 (Deposit disbursed: ) 208 508 -~ 209 Mortgage in favor of seller 509 Mortgage in favor of seller - Adjustments for items unpaid by seller Adjustments for items unpaid by seller 210 City/town taxes / / to / / 510 City/town taxes / / to / / .~ 211 County taxes / / to / / 511 County taxes / / to / / ~ -- 212 Assessments / / to / / 512 Assessments / / to / / --,- 213 513 - 214 514 -- 215 515 216 516 -- 217 517 218 518 - - -- 219 519 --'-.. --~ ~ Total}Jaid BylFor Borrower ,. 520 Total Reductionsfn*mount Due Seller 300 Cash At Settlement Fromffo Borrower 600 Cash At Settlement To/From Seller 301 Gross amount due from borrower [120] 20,250,00 601 Gross amount due to seller [420] . 20,250,00 302 Less amount paid by/for borrower [220] 602 Less reductions in amount due seller [520] .~ 303 Cash From Borrower 20,250.00 603 Cash To Seller 20,250,00 -. -,-~--- SUBSTITUTE FORM 1099-S SELLER'S STATEMENT: This is important tax information and is being furnished to the Internal Revenue Service, If you are required to tile a return, a negligence penalty or other sanction may be imposed on you if this item is required to be reported and the IRS determines that it has not been reported, The information in Boxes E, G, H, and I, the amount on Line 401 and the amount(s) of any real estate tax adjustments appearing on Lines 406 through 412 are reported to the IRS on Form 1099-S, REQUEST FOR SELLER'S TAXPA YER IDENTIFICATION AND CERTIFICA nON: You, the Seller (see Box E) are required by law to provide the Settlement Agent (see Box H) with your correct taxpayer identification number. If you do not provide the Settlement Agent with your correct taxpayer identification number, you may be subject to civil or criminal penalities imposed by law, By signing the following page of this Settlement Statement, you, under penalties of perjury, certify that the number shown on this statement (see Box E - "TIN") is your correct taxpayer identification number, Reesa™ Closing System for Windows™ HUD-l (Rev 3/86) L. Settlement Charges - - Paid from Paid from I 700 Total SaleslBroker's Commission Based on $ 20,250,00 @ %= borrower's seller's Division of commission (line 700) as follows: funds at funds at 701 to settlement settlement I 702 to -- --~ 703 Commission paid at settlement 704 Commission retained by 800 Items Payable In Connection With Loan 801 Loan origination fee %to ------ 802 Loan Discount %to -.--- ----- 803 Appraisal fee to: ---- 804 Credit report to: 805 Lender's inspection fee to ---~ 806 Mortgage insurance application fee to -- 807 Assumption fee to -------,- 808 -- 809 --- ------ 810 -- 811 900 Items Required By Lender To Be Paid In Advance - 901 Interest from / / to / / / day ---------- 902 Mortgage insurance premium for months to --------- 903 Hazard insurance premium for years to 904 Flood insurance premium for years to -~ 905 1000 Reserves Deposited With Lender 1001 Hazard insurance months @ J?er month --- ----------~--- 1002 Mortgage insurance months @ per month "_._----~ ---,--..------------ 1003 City property taxes months @ per month 1004 County property taxes months @ per month -- ----.-- 1005 Annual assessments months @ per month 1006 Flood insurance months @ per month --------------- 1007 months @ per month 1008 .--.----- --------~ 1100 Title Charges 1101 Settlement or closing fee to _n 1102 Abstract or title search to -----.-- 1103 Title examination to --- 1104 Title insurance binder to -~ 1105 Document preparation to -- 1106 Notary fees to 1107 Attorney's fees to includes above items ( ) 1108 . Title insurance fee to -- includes above iteins{ -.. - -.,-. } ._..,'.'. ---. 1109 Lender's coverage premium 1110 Owner's coverage premium ---- -. 1111 ---~-- 1112 -- 1113 1200 Government Recording And Transfer Charges 1201 Recording fees: Deed Mortgage Release --~--~--"_._.- 1202 City/county tax/stamps: Deed Mortgage - ---------- -- 1203 State tax/stamps: Deed Mortgage -,- 1204 ----- 1205 --- ------ 1300 Additional Settlement Charges 1301 Survey to --- ------- 1302 Pest inspection to ------.--.. 1303 ---- 1304 1305 ~ 1306 1307 1400 Totiil-setfiemenfCharges-- --- -. -.. - __. ___.,,_..__"__n_ .- -- , -- ----- .._____________- n.___ .-. -~- __ ___---.J I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accura!i statel~ent of all receipts and disbursements made "'my ~"Iha~_"".oopyOftb"H~'S"" - t I AI, ,. .r: - Darei' v,/?/ So" ., ,,1-'1 ....., Dare'~ City of Clearwater ' 1~ 'J: o~ IJ:ath ~ [f~~?jda corporatio Borrower: Date: Sell, -A A Date: / tJ Borrower: - Bapti~ sv s of Florida, l~.r ~fit FL corp. Date: Seller: Date: Borrower: Date: Seller: Date: The HUD-1 Settlement Statement which 1 have prepared is a true and accurate account of this transaction. 1 have caused or will cause the funds to be disbursed in accordance with this statement. Settlement Agent: Date: / / WARNING: It is a crime to knowingly make a false statement to the United States on this or any similar form. Penalties upon conviction include a fme and imorisonment. For details see Title 18 US Code Section 1001 and Section 1010. HUD-1 (Rev 3/86)