MAXINE DIXON
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RONALD (RON) E. SOMERS
President
1290 Court Street
Clearwater. Florida 34616
.""",.,it.. ,./ ('(Hllln,-t
S'l'E"V AIl'r 'rrl'I...E
OF CLEARWATER
P.O, Box 2756
Clearwater, Florida 34617
(813) 441-2689
AU'nIORIZATION AND ACKNOWLEDGEMENT FORM
Reference:
FILE NO.
91060110
LEGAL
rms 8, 9 and 11, LESS S 50' FOR STREET, BLK 2,
MOASE & HARRISON SUB
MAXINE DIXON
SELLER
BUYER
CITY OF CLEARWATER, FLORIDA
We hereby approve and acknowledge receipt of a copy of the Statement IDId actual
cost (DISCLOSURE/SETI'LlliENT STATEMENT - fRJD FORM 1) and authorized diSbursement
of funds as shown therein this 17 day of DECEMBER , 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 infonna.tion 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.
'!HAT ALL UITLITY BILLS (WATER, SE.Wm, ELEX:lRIC, MAlN.l'mANcE FEES) HAVE BEEN PAID
OR WILL BE PAID UPON REX::EIPl' OF FINAL BILLS.
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INITIALS
INITIALS
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MAXINE DIXON
SElLER I S FORWARDING ADDRESS:
BUYER. I S FORWARDING ADDRESS:
-f 7 O. 'B II '{, lCZ (P I
LcHZe-o, Fl-a. '3\f(PLf-9
,
HCl1E PHONEH HQ'1E PHONE#
hORK PHONE# Lf~ .;) - lj- I J y
WORK PHONE#
THIS IS TO FURTHER AlJIHORIZE
OJANGES NECESSARY TO '!HE CLOSING STATEMENT.
TO APPROVE; ANY
STE.WARr TITLE <n1PANY . 'OF CLFARWA'XER, INC.
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PREPARED FOR: CITY of- C""AR:WAIE..R.. EC, 12- TWP. Z9S. RGE. '~t.
ATToFP'" e:. y's T/TL-E:.. t,.J.su f\AtJcE. FUN D 1 NC.
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A SURVEY OF LOT 10, BLO(..K i, vf ,MOASE.. f I-\AR~I.sOJ..ls $Ue,-
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t>/VIS/O,..J Of LOT 7 of ~. H, PAD4E.TT5' $U80IVIS/ ON
AS RECORDED IN PLAT BOOK ~ , PAGE BS , OF THE PUBLIC RECORDS
OF Hi 11sborough County , Florida, of which Pinellas was fonrerly a part.
ZONE.- c, rE-~ CJTY Of GLEAf<WATE.R., M"'f PANEL 0015 (",-Ol-B?)
I HEREBY CERTIFY THAT THE SURVEY REPRESENTED HEREON MEETS THE MINIMUM
REQUIREMENTS OF CHAPTER 21 HH-6, OF THE FLORIDA ADMINISTRATIVE CODE.
DATE: '}-1,-91
OWN. BY: If..
INV, NO,: ql- 4~9
EVANS LAND SURVEYING
2300 MAIN STREET - UNIT' H
DUNEDIN, FLORIDA 33528 PH: 734 - 3821
&uNDARy SrJR,VE.'7' O;vl.-y
,.b BE FILLED IN PERSONALLIv
BY SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
MAXINE DIXON
Seller or Owner-Borrower
LOTS 8, 9 and 11, LESS S 50 I FOR S'IREET, BLK 2, MOASE & HARRISON SUB
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 on such property secured by a financing statement, security agreement or otherwise except the
following: (If none, so state,)
NAME AND ADDRESS OF SECURED PARTY Approximate Amount
~ ~\\ one... '(Y\.[').
.
2, No loans of any kind on said property except the following: (If none, so state,)
NAME AND ADDRESS OF CREDITOR Approximate Amount
1- .Tlrm ~ - YVl LJ .
3, AU 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 aU 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 MA TERIALS Approximate Amount
f,1l r))'l e - 'n,./)
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 MA TERIALS 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 thp.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 ATTORNEY'S FEES THAT SAID PARTIES MAY INCUR IN CONNECTION WITH SUCH UNMENTlQNED
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,
IreaUze that the purchaser and / or lender in this transaction are relying on the representation contained herein in purchasing
same or lending money thereon and would not purchase same or lend money thereon unless said representations were made,
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MAXINE DIXON
SWORN TO AND SUBSCRIBED BEFORE ME THIS
I {.;1f1
day of
DECEMBER
91
,19_,
My Commission Expires: /f cJ 0 y;;)J
Rev. 1/88
NOTE: This form il to be liped by ...Ie, in .... of ..Ie. If no ..Ie,1t is 10 be liped by lhe 0_'-...."0'"'. If lhere is Iny new conotruotion, 1M conl'loIo, mUlt 1110 join in Ihit form
or .i." . aeparale OM.
/
MIS LDI ,-_/' . ' . I . PAGE 2 OF OMS No, 2502-0265
. t . . PAID FROM PAID FROM
L. SETTLEMENT CHARGES BORROWER'S SELLER'S
FUNDS FUNDS
700. TOTAL SALES/BROKER'S COMMISSION Baaed 011 price' 130,000.00 @ %= 10 000.00 AT SETTlEMENT AT SETTLEMENT
Division 01 commission (line 7(J()) as follows:
701$ * 7,249.26 to BLAN-EDWARDS REALTY. INC.
702. $ to
703, Commission paid at selllement * LESS S2750.74 '!(MARDS SELLER CLOSING COSTS * 10 ("\rV\ f'lf'l
704.
800 ITEMS PAYABLE IN CONNECTION WITH lOAN.
801. Loan Origination fee %
802, Loan Discount %
803, Appraisal Fee to
804. Credit Re~ort to
805, Lender's inspection fee
806, Mortgage Insurance application fee to
807. Assumption Fee
808.
809.
810.
811.
900 ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE,
901.Interest tram to @$ /day
902, Mortgage insurance premium for mo, to
903, Hazard insurance premium for yrs, to
904. yrs, to
905.
1000. RESERVES DEPOSITED WITH lENDER
1001. Hazard insurance mO,@$ per mo, - ,
1002 Mortgage insurance mO,@$ per mo,
1003, City property taxes mO,@$ per mo, ..
1004, County property taxes mo,@$ per mo, l ;, 't' ~
1005, Annual assessments (Main!.) mO,@$ per mo,
1006. mo,@$ per mo,
1007, mo,@$ permo,
1008. mO,@$ pe' mo,
1100 TITlE CHARGES:
1101. Setllement or closing fee 10
1102, Abstract or title search 10 STC * 300.00
1103, Tille examination to
1104. Title insurance binder to
1105 Document preparalion to
1106 Notary tees to
1107. Allorney's tees to to
" ,,', If
(includes above items No, '
1108, Title insurance (1101) toSTEWART TITLE CCX\1PANY OF CLEARWATER. INC. * 1 210.00
(includes above items No,: , .,
1109, Lender's coverage $
1110, Owner's coverage $ 130,000.00 ,
'11,
1111.
1112,
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording lees: Deed $ 43.00 Mortgage $ Releases $ 6.00 JUDGEMENT /MYRI Ix 43.00 6.00
1202, Citylcounty tax/stamps: Deed $ Mortgage $
1203, Slate tax/stamps: Deed $ 780.00 Mortgage $ * 7AOOO
1204. RECORD AFFIDAVITS/CHARLES. DELORES. JOSEPH JEANETI'E
1205. 4 @ 6.00 ~AMJ ?4,OO
1206. RECORD SATISFAcrION OF JUDGEMENT/JOSEPH FREDRRIrK DIX()l\l 10 C:;0
1300 ADDITIONAL SETTlEMENT CHARGES
1301. Survey to EVANS LAND SURVEYING POC
1302, Pest inspection to NOr 1-1"1 H I"'STED OR RFnUIRED
1303. MAILAWAY PREPARATION/COURIER ?hE; on
1304. CITY OF CLEARWATER-LIEN SEARCH * C:;,OO
1305
1400 TOTAL SETTlEMENT CHARGES (entered on lines 103,~ectlOn J and 502,~ect/on K) LL~ nn l? hnn t:;n
CERTIFICATION: I have carefully reviewed the HUD-l Selllement Stalement and 10 Ihl bast of my knowlldllllnd blUlf, IliulNI Ind Iccurlll statement 01 all receipts and dlsbu,sementa mldeon my account or by me In Ihls transactlon,f lu;thercertlly
that I have received a copy 01 HUD-l Settlement Statemlnt
Vi" CLt!Al<WAT12<
l' t y \ M.cL:. ,_, L) A'A.tIL,;j
Sailers
true and accurate aa:ounl of Ihe funds which were received and have been or will be disbursed by the undersigned as part of the seUlement 01 this transaction,
,
U~CU~~K 1/, l~~l
SeUlement Agent,..' Date
SEllER'S AND/OR PURCHASER'S STATEMENT Seller's and Purchaser's signature hereon ecknowledgls hlslthelr app,ovaf oltn prorations Ind signllles their understanding that prorations were based on tlltes for the preceding year, or estimales
lor the current year, and in the event 01 any change lor the current year, all necessary adjustments musl III made between Saller Ind Purchaser; likewise Iny defaull in delinquent taxes will be reimbursed to Tille Company by the Saller.
TlUe Company, in lis capacity as Escrow Agent, is and has been authorized to deposlllU funds II rlcelves In this trlnsaction In Iny IInancllflnslltutlon, whathlr afllliated or not Such flnlnclal instllution may provide Tille Complny computer
accounting and audit services directly or through a sepa'ate entlly which, If afllllaled with TIIII Complny, may chlrgelhlllnancllllnstltutlon reasonlbleand proparcompansltlon Ihe'e'orl Ind rltlin any prollta Iheref,om, Any esc,ow fees gild by any
party involved in this transacllon shall only III for checkw,illng and Input to Ihe compute,s, but nollo, aforeslld Iccountlng and ludllIIrvlcas, Title Complny shill not IlIlIlbllfo, Iny Intlrlst or other cha'ges on the elrnest money, Ind shall e under no
duty to Invest or reinvest funds held by it at any lime, Sellers and Purchlslrs hlreby acknowledge Ind consenlto thadeposlI oltha ..crow monay In IInlnclal inslltutlons wllh which Title Company hiS or mlY heye other blnklng ,e alionshlps Ind further
consent to the retention by Tille Company and/or its affiliates of any Ind all benefits (Including advantageous Interlst ratls on loans) TIlII Company and lor its affiliates may receivI tram such financial institutions by reason 01 their maintenance of said
escrow accounls.
The parlles have read the above sentences, recognize that the recllallons herein are materlll, agree to same, and recognizl Title Company is relying on tha same, 'i"
purchasersQyl:~l'1'Y 01" CLrJlliW~1't;l{ . ~:~~~~~~:_A~_)_~ A~t_~'~___n
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RONALD (RONI E. SOMERS
President
S~l"EWAII~l" ~rrl'I~E
OF CLEARWATER
P.O. 80)( 2756
Clearwater, Florida 34617
(813) 441-2689
1290 Court St,eet
Clearwater, Florida 34616
D I S C LOS U R E
We, the Owners of that certain real property located at
LOTS 8,9 and 11, LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON SUB
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.
''--fY\ ~'4(.', 1 ) D .A4n. ')
W1tness
Yl:Jh((}(~/J/J~
,W1 tnes s
MAXIr:JE DIXON
STATE OF
COUNTY OF
FLORIDA
PINELlAS
SWORN'TO AND SUBSCRIBED BEFORE ME THIS
/0Tf
DAY OF
DECEMBER
, 19 91.
My Commission Expires~ ;:?7t/- f;}
-
fD) '.... ~,@~u_. n W~l.....lml.,.. ~. ' .
lIl1 i DEG 9 1991 .1 ~':) I
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pur:'E~~',C;"'Ci' -'_, ._~::iI_ .i;
~
BLAN~DWARDS REAlTY, Inc.
531 11 th STREET
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PALM HARBOR; FL 3~83
dC^ ~NG'Na:RING GROUP
CM'i 0 TCJ 0 PJ QJVH
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coP/a; TO: a GPB
Ail:: --
December 5, 1991
TEl. 813-785-5641
-
Re: Sale contract dated June 3, 1991 between City of
Clearwater (buyer) and Bernard.Dixon, Janette
Hamilton, etux.
Lots 8, 9 & 11 Less South 50' for Road Moase & Harrison
Sub., Block 2. AKA 1139 Brownell Street, Clearwater, Fl
The City of Clearwater and Blan-Edwards Realty, Inc., have
agreed to payoff the judgement against Joseph Dixon in the
amount of $5,451.62. City of Clearwater and Blan-Edwards
to each pay half of the above amount. Closing date set for
December 17, 1991
a~~/
Edward J. Henry
Realtor-Associate
&
\-
Mailing Address: P.O. BOX 1316, PALM HARBOR, FL 34682
(r
dhouldn't t~ ta'9ut pU'r.ahau. of !Jou't life. c.ome. wUh a wananty?
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INFORMATION FOR REAL ESTATE 1099-S REPORT 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 ybu 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: · 910601110
Taxpayer ID Number: Seller 1 'l.. .:l. (Q 7 - ~ ~- ~ 35\.. Seller 2
Taxpayer ID Type:
2
~1 = business, 2 = individual)
SELLER 1 NAME:
DIXON
Last:
First & Middle:
MAXINE
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1 :-J, ....0
Street: .. I. 0 · 13, 0 )(
City: L oV'~ u
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State: F~Q.
Zip Code: 3 .l.f~ Y-9
SELLER 2:
Street:
City:
State:
'Zip Code:
TRANSACTION INFORMATION
Closing Date (MMDDYY):
12/17/91
Contract Sales Price: Seller 1 -
10,000.00
Seller 2 -
(If multiple sellers please allocate the sales price among the sellers)
Description of Property:
Street Address: 1127 & 1139, BROWNELL S'IREET, CLEARWATER, FL 34616
Legal Description: LOTS 8,9 and 11, LESS S 50' FOR STREET, BLK 2. MOASE & HARRISON SUB
Under penal ties of perjury, I, MAXINE DIXON
(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.
Da te: '-h /;) / Jr(J / 91
Seller - 1 Signature: .-J-.- 'TYlQl.....l~(~..r) fj.~01~
MAXINE DIX N
Date:
Seller - 2 Signature:
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE c:.'G1PANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT SIREEl'
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 10 Number:
59-1433918
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NUN-l;'OIU~Lt;N CEH'1'LfJ.C^'l'.LOH BY HIIJ.l.VJIJU^I, 'nU\I~Sn!;1l0H
1. ~;ecU.ulI V1~!j or Lho JIILel:lla.t Hevellue Coue pruvJuen Umt 0 Lrd\lsfet-ee u[ 0 Ullited
States t-eDl pwperty illterest l1lust withhu.td tux if the tnlllsfet:or is IJ foteiy" tJet-SOIl.
2. J.II older Lo 1111:01.111 lite Lnlllsfetee lhut wllhho.luJIIV of: lox Ju IIOt l'equheu lIpon Lhe
d.lspos.l.u.on hy MAXINE DIXON
Qf1he UIIllel1 SLoLes real property tlescdbeu os [ollows:
LOTS 8,9 and 11, LESS S 50 I FUR STREET, BLK 2, MOASE & HARRISON SUB
lhe ulluelsigl1el1 transferor certifies onu declares Uy Illeans of LIlis certificat!oll, Lhe
followillg:
(a) I (We) alii (ore) 110t Iloll-residellt o11ell(s) for p.trposes of Ullitetl SloLes income
laxotion 011(1,
(b) Ny Ullilr.-d Stotes Laypoper identifyiltg 1l1lIl1ber(S) (Social Securily Number) is/ore:
~ SOCl1\l.. S~X:U1U'1',{ NUI'~
MAXINE DIXON
,,:J. d- ~ 7- '3 ~ - 9 3 ~'lc
If
"
"
(c) Ny hOllle nddreus 19
(u ttod leU t1tklJ U.OllO.1 puUe .i.f lIecessm:y)
(d) Thete ore 110 olher lJe.rSOIl9 who Ituve nil OWIIOJ:SItJp JIILerest ill Lhl! uIXJve-ueSl:r.l.~d
prol,JetLy oLhl?!r limn lhose lJeJ:solts set f()l'UI ul.x>ve ill subpr:u:oyroplt (b).
J. 'Jhe 1I11t1elsJ.gncd hereby [Ut"tlter cert.tfJ.es OIKJ uecJ.ol'es:
(0) I (Wp,) \J11<.let:stolld thot the purchoser of lhe above described prolX!rty illLenus .
lo r.oly 011 Lho f:otogoillU representatIol1s JII COl1l1ecLtoll wlLh lhe lln.l.ted SLuLes
(PorelYII InvesLlIlel1l ill Heal Property '1'tlx 1\ct. (91 Statute 2(;02 OS 1lII1elldl!d).
(b) .I. (WI!) uI1det:nLulld LltJs cerUr.t.cat.l.oll Ilny l~ tllsG.1.oned Lo Lltn lllLerllal Hev81lue
Ser.v.i.ce by tt:ol1sreree olld that OilY false atotelllenl:. contained ill Lhls ceruncaUoll
IIli.lY lJo IJun.l.r:;It(!tI hy UIIH, J,Itlpt.l.nolllllont 01: both.
Ulldor pmlUlUes of perjury 1 (we) ueclare I (we) have eXb.mllled carefUlly lills certi-
ficotioll 011(] it is It-ue, correct Oltd complete.
ot
PINELLAS
COUllty,
FLORIDA
- -J-- Yn G4( J', . !); 'i({l, I
MAXINE DIXON
W tll BS
('1hio dOCllhlenl:. hust be retained until the end of the fifth taxable year following the~1
taxable year JI1 wh.lch the trausler laltes place).
CONSUfJl' YOUn NrlUHNI!:'{ 1\NIJ/OIt 'l'1\X 1\IJVlSOlt - No ltEPlU!:SW1'1\'1'1ON on lU~:c.'(XI1I'1r~"NUl\'l'lON IS N1\IJl~ uy
STE.Wl\In' 'J.'.l'J'LI~ INSlm1\NCI~ Ol\1PI\NY 1\NIJ/OH CONCl~HNJNG TIll!:
UX;l\I.J SUFFJCJU~CY 1\NIJ/OIl 'J'l\X CONSQUI1'NCES OIl' 'l1lJ.S lXJCUI'1I~ti,i\You N^Y 1m lU~QUlmu '1'0 F'lI,l~
1\ COpy Ol~ TilLS l.xX:IJMUtl.' W,I '1'11 'l'''I~ IN'l'EHN/\rJ lU!.Vr~\JI~ SI~nV.tCI!:. 'J1I1!;SI~ /\IU~ QUl~S'l'.tONS ron YOUH
1\T1'()nNI~'i on TAX 1\IJV 1 SUH.
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COUt-lly O~1
FLORIDA
PINELLAS
I IIEIU!:UY CIr.H'l'll''Y that on L1tLs day, before Ine, all officer uUly authorized ill lhe State
aforesaid and ill lite Coul1ty oforesaid to take oclmowJ.edymel1ta, persol1olly (1ppeared
MAXINE DIXON
to me Itl10wn to be lhe lJel:sCJIlS described ill alld who executed tho foregoil1g 11lSLnllllellt
ol1d they OC"-Ilowlroged oo(ot:e hIe that they executed the SOllk!.
Wl'l'NESS my halltl Dud officiol seal ill the Coultty nud SLate lost aforesoid Ud.s uuy
of DECEMBER , 19 <}1 .
'.
~HY l\JUJA,C
MY Cal'lISSION EXPllU~ l