SALLY JO FORESTER
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91030096
....'" I~ R RAN T Y () L l 0 I
INDIVID. TO 1~~DIVJD "
INST t 91-167395 PINELLAS COUNTY FLA.
.... _JUN..?_4LJ9~~;~<?Pt1.,.1 OFF..R,Ei:l,:. BIS-'Z{>J~4 PG 2374
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lhis UliU'ranty j[Jrrd f'.!",{l' /Iil' , ,1-I':zt-c..= ,{(IV ()r,.A,~
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SALLY JO FORESTER, a' rVllVv~ woman, as one of
SKYLARK OPPORTUNITIES, A Florida general partnership
(1(>rI';lIfl!I(>r called "I(' Wflll/Ol, 10
Jrme,
1\ . f) I C)
91 /)y
the surviving partners of
CI1Y OF CLEARWATER, FIDRIDA
II,I'I,se posloFfice add,l'ss is P.O. Box 4748, Clearwater, Florida 34618
',(',eillflfler called II,e fI/,(/lIll'l':
(\\'herf'Vt"f 11\("<.1 h(,ll~ill rill' (erllls "I,(,alllor" and "~ralltt'l'" include all tbe parties to Ihis inSlr\lnll~nt and
the hf'ir,. Il'.~al r'('pn~\"lltalj\'(.s and a~\i~lI:-' (If individuah, "'1(1 (he .,u(:n"ssors and assil.{lls of corporation...)
llil.fUnesseth: Tll(/I II,e wall lor. for allcl in consicle/'(//ioll of III(' sum of $ 10.00
pallla/,le consic{eralions. rl>ceipl wlwrl>of is I.ere/)y ackno[J'{(>(frwcl, IU>le/JY flranls. /)(Irf/nins,
mises. releases, corll'eys and confirms ulllo III(' flrunlee. all 1/1(/1 ceria ill land siluale in
Counly, Florida. (liz:
am[ olll('r
sells. nliens. re-
Pinellas
Lot 4, JANIE DANIELS SUBDIVISION, according to the plat thereof, as recorded
in Plat Book 5, Page 23 of the Public Records of Pinellas Cormty, Florida.
parcel number 15/29/15/29286/000/0040
grantors social sec. II '.:l7lf-'{lZ-' 3Si-S (SALLY JO)
) .1'
Property is not the principal residence of the Grantor, she in fact resides at:
, &; (7:J 5). t-fa.,[,{((xi Sf ) rt~( (R(j:.J;7Lva , lit 11/'-/7
OOCIJ!T1"''1t;>.v Tax P,i. ~._~.W
--- --
$ --.---.-. !:-tP" ~~;:'~ Ta': Pd.
KErleen F. De\}~;'W8rl<. ri:Jdi:ilS C<;::rlty
Bv U - c~"uty Clerk
willi all Ihe tenements, hereditaments and appurlenances thereto belonging or in any-
logtthtr
wise appertaining.
To Jtaut and to Jtold,
the same in fee simple forever.
Rod tlte grantor herel,y covenanls with said grantee Ihal Ihe grantor is lawfully seized of said land
in fee simple; thaI the grantor has good rigId and lawful authority to sell and convey said land; that the
gran lor hereby fully warrants the title to said land and will defend the same against the lawful claims of
all persons whomsoe(ler; and that said land is free of all encumbrances. except taxes accruing subsequent
to ~ June 24, 1991 and easements and restrictions of record~
,. .~K
KARLEEN F. DEBLAK~~'-
RJ;": t;QF<[1 Vr::131F IE D 1:1)' · "
In ltfitntsS ltfhtrtof, the said grantor has signed and sealed Ihese presents the day and year
first above written.
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'(>~Illi~~..'...,~'?:;;;..,-.__._.."i-..--'
. _.__. _. __ ___. __. _ __,. ___ _.. _. __ _..._ u. __.._. ___ ___ _. __.. ___ ____ _.... ___ _ __,. u.aD
C' ,
STATE OF .p~I'nc:;yhT~ni....:l.... 111J6S/1C~e rrs
COUNTY OF I .~ilrUUCE- r- . \
SPAce UlOW FOR RECORDERS USE
I HEREBY CERTIFY that on this day, before me, an officer duly
authorized in the State aforesaid and in the County aforesaid to take
acknowledgments, personally appeared
I -
SALLY JO FORESTER, a 1/nUiI1~.ewoman as one of t
surviving partners of SKYLARK OPPORTUNITIES, a Flori
to me known to be the person described in and who executl"d the
foregoing instru,men~ and she acknowledged before me that she
executed the:,Jame. ..
: "" :"WI'iI.ttf.~S my hand and official seal in the County and
[;.lak~ te I.,,~.~~.~rort'said this I' day of
",,\. ...'....i. ',' '. June -2 ,A. D. 19 91
,;::.~;:..''?'J;.:~~ a_' ~
.7'W}~t!j~;~tt~L!!~~~~~~~ .
Ajd:<i;'~:~.'.'~..'..',:>-' rj~ 7
"" /'1 i"':
e
a general
partnership
RQ1uA.fl
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rh',' Im;n
,\":,::.~,\nn~~ b~;
S'H:WAIH 'I, 'i,:':AR'it'ATEr~
By: Mi kell...L..",BL_.Germain
L: <. ~:H;: ~:':;','''r>,:~
CI"",' ,""1', !i;i,:,'jt\16
r.'~J. ~~)O% 2"i.5b
/
C1~iu\",h'. FL 34617
Whkh ln~tnm"".i ..a'. prepared incidental
:to wrihnll of <I. Titi", 1,,.,,,.llfH\(,e Policy.
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RONALD (RON) E. SOMERS
President
S~"lE'V AII'T 'TrrI.JE
OF CLEARWATER
P.O. Box 2756
Clearwater, Florida 34617
(813) 441,2689
1290 Cou rt Street
Clearwater. Florida 34616
D I S C LOS U R E
We, the Owners of that certain real property located at
rm 4, JANIE DANIELS SUBDIVISION
Pinellas County, Florida, do hereby disclose the following facts
known to me which may materially affect the value or desirability
of said property.
I HEREBY CERTIFY that I have no knowledge of any facts or
defects in said property which may materially effect the value or
desirability of said property, except as set forth above. I
acknowledge that this disclosure will be given to the listing
broker, the selling broker, and any prospective buyer.
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V~/:dfHf;m. ~au
1tness
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SALLY JO FOREST .,-
()?t!l:!!7> Cl.~
STATE OF .['ErlNGYI.:JMUA
(~ /}., _ _..J. ~
COUNTY OrV'/~a
l~
SWORN TO AND SUBSCRIBED BEFORE ME THIS~ cP/J ~
DAY OF
JUNE
19 91 .
(Q
My Commission Expires: v
r //2-/r 1
~,9~?7J.~~
Notary Public ~
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INFORMATION FOR REAL ESTATE 1099-S REPORT FILING
,I
Section 6045 of the Internal Revenue Code, as amended by the Tax
Reform Act of 1986, requires the reporting of certain information on
every real estate transaction. From the information you provide
below, a Form 1099-s will be produced, a copy of it will be furnished
to the I.R.S. and to you no later than January 31 of the next year,
and a copy may be sent to other third parties. If you fail to furnish
adequate information (in particular, a taxpayer 10 number), then you
will be subject to all I.R.Si Regulations, including the possible
withholding of twenty percent (20%) of the current sales price.
File Number:
..
91030096
Taxpayer 10 Number:Seller 1 ~1,-/~l(lr7)C(( Seller 2
Taxpayer 10 Type: 2
SELLER 1 NAME:
Last: FORESTER
SELLER 2 NAME:
Last:
(1 = business, 2 = individual)
First & Middle:
SALLY JO
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: ,\ _
Street: ,y"'" t..o \~ S , ~~,-~ck-. S;C-.
C it y: v~ t-4-7Y7- L?zJ-.A; Sta tet:-- ~
Zip Code-:-- l 91 L{ 1
SELLER 2:
Street:
City:
State:
Zip Code:
TRANSACTION INFORMATION
Closing Date (MMDDYY):
JUNE 24, 1991
Contract Sales Price: Seller 1 -
xx~ 15,750.00
Seller 2 -
(If multiple sellers please allocate the sales price among the sellers)
Description of Property:
Street Address:
Legal Description:
LOT 4, JANIE DANIELS SUBDIVISION
Under penalties of perjury, I,
SALLY JO FORESTER
(Name of Seller (s))
certify that the number shown on this form is my correct. Taxpayer
Identification Number and that the other information is correct to the
best of my understanding and I understand that it will appear on a Form
1099-S that will be sent to me and to the Internal Revenue Service.
,~
Seller - 1 Signature:~~Y?J~';;-mfu~---(~
Seller - 2 Signature:
Date: ~{^'-(. vI /4""1/
l
Date:
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE COMPANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 10 Number:
59-1433918
-.
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INFORMATIoJ FOR REAL ESTATE 1099-S REPlRT FILING
.'
Section 6045 of the Internal Revenue Code, as amended by the Tax
Reform Act of 1986, requires the reporting of certain information on
every real estate transaction. From the information you provide
below, a Form 1099-s will be produced, a copy of it will be furnished
to the I.R.S. and to you no later than January 31 of the next year,
and a copy may be sent to other third parties. If you fail to furnish
adequate information (in particular, a taxpayer ID number), then you
will be subject to all I.R.S. Regulations, including the possible
withholding of twenty percent (20%) of the current sales price.
File Number:
91030096
Taxpayer ID Number:Seller 1 V""tl-1L/-1{~r7)C{( Seller 2
Taxpayer ID Type:
2
~1 = business, 2 = individual)
SELLER 1 NAME:
Last:
FORESTER
First & Middle:
SALLY JO
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: 1\ ,
Street: /'" Co \~ s, ~t0.,--~c:.k.. S:c,
City: V~l-A:-7./$-~A Statet:- ~
SELLER 2:
Street:
Zip Cod~ l 91 L{ 1
City:
State:
Zip Code:
TRANSACTION INFORMATION
Closing Date (MMDDYY):
JUNE 24, 1991
Contract Sales Price: Seller 1 -
15,000.00
Seller 2 -
(If multiple sellers please allocate the sales prlce among the sellers)
Description of Property:
Street Address:
Legal Description:
LOr 4, JANIE DANIELS SUBDIVISION
Under penal ties of perjury, I, SALLY JO FORESTER
(Name of Seller (s))
certify that the number shown on this form is my correct Taxpayer
Identification Number and that the other information is correct to the
best of my understanding and I understand that it will appear on a Form
1099-S that will be sent to me and to the Internal Revenue Service.
Date:~",-!- -lA, I:"l'" Seller - 1 Signature:~~~...~- .
SALLY JO FOR&; ~'
Date: Seller - 2 Signature:
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE COMPANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer ID Number:
59-1433918
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."""","ti,) III ("o""orl
RONALD(RONIE.SOMERS
President
1290 Court Street
Clearwater, Florida 34616
s'rEWAI~T 'rrrIAE
OF CLE^RW^TER
P.O. Box 2756
Clearwater, Florida 34617
(813) 441-2689
AtJI'HORIZATION AND ACKNOWLEI:X;EMENT FORM
Reference:
FILE NO.
91030096
LEGAL
LOT 4, JANIE DANIELS SUBDIVISION
SELLER
SALLY JO FORESTER
BUYER
We hereby approve and acknowledge receipt of a copy of the Statement and actual
cost (DISCLOSURE/SETTLEMENT STATEMENT - HUD FORM 1) and authorized disbursement
of funds as shown therein this 24 day of JUNE , 19 91. We further
acknowledge that we understand utility bills are not included in this statement
and that the proration of taxes as shown in the statement of actual cost is
based on the latest infonnation available. If any changes are to be made in this
proration when the tax bill is received, it will be handled between the parties of
this transaction. Stewart Title Company of Clearwater, Inc., will not be held
responsible. It is further understood that Stewart Title Company of Clearwater,
Inc., cannot, at this time, assertain if there will be personal property tax on
subject property or an amount on which to base a proration. Any proration necessary
when tax bills become available will be handled between the parties to this
transaction, outside of Stewart Title Company Company of Clearwater, Inc.
Stewart Title Company of Clearwater, Inc., will be not held responsible.
~g
SALLY JO FORESTER
,4;
SELLER'S FORWARDING ADDRESS:
BUYER'S FORWARDING 'ADDRESS:
/' ro t'O S, fl-A-NC9CL Sll
t/P1-h~2:Li?tfrA- ) tfl 111 t.f7
HCl1E PHONE# t:l~~) 1Z'3-<OLlod
WJRK PHONE# /~ S'J ~~ cq - <15l L
~
HCl1E PHONE#
WORK PHONE#
'!HIS IS TO FURTHER AUTHORIZE
OIANGES NECESSARY TO TIlE CLOSING srATENENT.
TO APPROVE'. ANY
STEWART TITLE COMPANY OF CLEARWATER, INC.
BY:
{ ,",
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NON-FOHEIGN CEH'l'.LF'lCNl'lON BY INIJIVIDUl\L 'l'Hl\NSF'EHOH
1. Section 1145 of the Internal Hevenue Code provides that a lrct\lSferee i)[ a United
Slates real property interest IIlUSt withhold Lax if the transferor is (j foreign person.
2. In order to inronll the trans[et-ee that withholding or tax is not required U[XJn the
dis[XJs.i. lion by SALLY JO FORESTER
of the United States leal property described as follows:
r.m 4, JANIE DANIELS SUBDIVISION
the undersigned transferor certifies and declares by means of this certification, the
following:
(a) I (We) am (are) not non-resident alien(s) for purposes of United States income
taxa Lion uw'l,
(b) My Uni!cd States
Nl\ME
SALLY JO FORESTER
taypaper identifying number(s) (Social Security NWllber)
SOCIl\TJ SF,cUIU'l'Y NUMDER
CD
' #~ .;l7Y- YJ--3~C\S
f~
it
#
is/are:
(c) ~1y hom8 ml<1ress is
(attached udc1itional page if necessary)
(<1) There are no other: persons who huve un ownership interest in the above-descd.ood
property othor than those persons set forth C1bove ill subparagraph (b).
3. 'J11e undersigned hereby further certifies and declares:
(a) I (We) understand that the purchaser of the above described property intends
to rely on the foregoing representations in connection with the United Stutes
l"oreign Investment in Heal Property 'l'ax l\ct. (94 Statute 2602 as amended).
(b) :I. (we) under.sl,llld this certification lIlay be disclosed to the Internal Hevenue
Service by transferee and that any false statement contained in this certification
lI1ay be pll\1.i.f31Ied by fille, .i.mprisolllllent or Loth.
Under penalties of
fication and it is
(~
JUNEv f) {\ 1991
0.~~~1.~~
b/' {)./. f)o~J
Wit ss,
('1'\ . s document must be retained until the end of the fifth taxable year following the "
taxable year in which the transfer takes place).
CONSUL'l' YOU/{ l\'lTORNEY ANn/OR 'I'l\X l\DVISOR - NO REPHESEN'l'l\'l'ION OR RECOMMENDl\TION IS Ml\DE BY
STEWAH'l' 'J.'.l'l'LE INSURl\NCE Ce~pl\.NY l\ND/OR CONCERNING THE
LEGl\TJ SUrFJCIE:NCY l\ND/OR 'J'l\X CONSQUI!:NCE:S Oli' 'UllS DOCUl\1E:N'1'. YOU Ml\Y BE REQUlm:o TO FILE
l\ COPY OF' 'l'IIIS DOClJMFNl' Wl'l1I 'l'llI~ IN'l'ERNl\T, mWI!:NlJl~ SJ~HVICE. '.I11ESr. l\RE QUr.STIONS FOR YOUn
l\'l'ronNIN em 'J.'l\X l\DVISOR.
STl\TE OF .{'EiNNGYL'yTNUA 1>>d.4..:1~
COUN'l'Y or~) '7{~~
I HEREBY CI~HTIF'Y that on this day, before me, an officer duly authorized in the State
aforesaid and in the County af.oresaid to take acknowledgments, personally llppeared
SALLY JO FORESTER
to me known to be the persons described in and who executed the foregoing instrument
and they acknowledged before me that they executed the same. l ( l)
J.:..---
WITNESS my hand and official seal in the County and State last aforesaid this r.V / day
of JUNE , 19 91.
Date
perjury I (we) declare I (we) have
true, correct and complete.
CY
at~
examined carefUlly this certi-
rV1 fl<; SI4~r;a()
PlSNNSXL\'l\fHA
(~~0Ju-~
NOl'ARY PUULIC ~/___ j. /"
MY CCl'lI'lISSION EXPWES: 9 ,2 / Y 7
. (i~
()E:' C\
.
. . - ..
~O BE FILLED IN PERSONALly
BY SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
SALLY JO FORESTER
Seller or Owner-Borrower
wr 4 JANIE DANIELS SUBDIVISION
Contractor (if new construction)
Purchaser
personally known to me to be the person whose name is subscribed hereto, and upon his oath deposes and says:
I, the seller, owner-borrower, and/or contractor, represent to the purchaser and/or lender in this transaction
that to my knowledge there are:
1. No unpaid debts for plumbing fixtures, water heaters, floor furnaces, air conditioners, radio or television an-
tennae, carpeting, rugs, lawn sprinkling systems, venetian blinds, window shades, draperies, electric appliances,
fences, street paving, or any personal property or fixtures that are located on the subject property described
above, and that no such items have been purchased on time payment contracts, and there are no security
interests oq such property secured by a financing statement, security agreement or otherwise except the
following: (If none, so state.)
NAME AND ADDRESS OF SECURED PARTY
CD ApproximlJ!e Amo~~_
'~C)-O ~
.
2. No loans of any kind on said property except the following: (If none, so state.)
NAME AND ADDRESS OF CREDITOR @ Approximate A~
~ <b.o
3. All labor and material used in the construction of improvements or repairs on the above described property
have been paid for and there are now no unpaid labor or material claims against the improvements or the
property upon which same are situated, and I hereby declare that all sums of money due for the erection of
improvements or repairs have been fully paid and satisfied, except: (If none. so state.)
NAME AND ADDRESS OF SUPPLIER OF LABOR, SERVICES OR MATERIALS @ Approximate Amount
~O.O ~
4. I, the purchaser, represent that I have no knowledge of any debts or liens of any kind other than those listed
above, except: (If none, so state.)
NAME AND ADDRESS OF SECURED PARTY, CREDITOR, SUPPLIER OF
LABOR OR MATERIALS Approximate Amount
S. I, the owner-borrower, or purchaser, have not been given notice of the furnishing or intent to furnish any labor,
services, or materials in connection with any improvements or repairs to said property from any person or firms,
except: (If none, so state.)
SUPPLIER OR LABOR, SERVICES OR MATERIALS ADDRESS
6. I. the undersigned owner, further certify tht'.t the real estate and personal property above described are in the
actual possession of the undersigned and is not in the possession, actual or constructive, of any person, persons,
or organizations holding or claiming same, adversely to the undersigned under contract, lease, or any other color
of title or right of possession.
The improvements or repairs to said property are now completed and have been accepted by purchaser and/or
owner-borrower.
INDEMNITY: I, THE SELLER, OWNER-BORROWER, AND/OR CONTRACTOR, AGREE TO PAY ON DEMAND
TO THE PURCHASERS AND/OR LENDER IN THIS TRANSACTION, THEIR SUCCESSORS AND ASSIGNS, ALL
AMOUNTS SECURED BY ANY AND ALL LIENS NOT SHOWN ABOVE, TOGETHER WITH ALL COSTS, LOSS
AND AITORNEY'S FEES THAT SAID PARTIES MAY INCUR IN CONNECTION WITH SUCH UNMENTIQNED
LIENS, PROVIDED SAID LIENS EITHER CURRENTLY APPLY TO SUBJECT PROPERTY, OR A PART THERE-
OF, OR ARE SUBSEQUENTLY ESTABLISHED AGAINST SAID PROPERTY AND ARE CREATED BY ME,
KNOWN TO ME OR HAVE AN INCEPTION DATE PRIOR TO THE CONSUMMATION OF THIS TRANSACTION.
1..1
I realize that the purchaser and/or lender in this transaction are relying on the representation contained herein in purchasing
5 or in~ ~~r tb~ . On a ou~~ not purchase same or lend money thereon unless said representations were made.
'--" I- ~_,,\ " ~~ '>
SALLY JO FORESTER
Ir'_
SWORN TO AND SUBSCRIBED BEFORE ME THIS -1 / day of
JUNE
91
,19_.
....-'
9~~7
v/'"
Notary Public in and for'/
I ".!I
Rev. 1/88
My Commission Expires:
"'PBNN5'tLVANIA /-T ~/
/J'! ~?SS cl ~,L4(, L0
NOTE: Thil form is 10 be si.ned by .eller in cIISe of salc. If no sait, il ia 10 be .ipd by the owncr.borrower. If there it any new con.truction. the contractor mUll allo join in th
or sian a StpU&IC one