AUDREY DIXON MYRICK
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."n""t;t, It! Conlln,.t
RONALD (RON) E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
S'l'EWAI{'r'l'rrJ.....E
OF CLEARWATER
r.o, 80)( 2756
Clearwater, Florida 34617
(813) 441,2689
AU'l1I0RIZATION AND ACKNOWLE[x;EMENT FORM
Reference:
FILE NO.
91060110
LEx;AL
wrs 8,9 and 11, LESS S 50' FOR STREET, BLK 2,
SELLER
AUDREY DIXON MYRICK
MOASE & HARRISON SUB
BUYER
CITY OF CLEARWATER, FLORIDA
We hereby approve and acknowledge receipt of a copy of the Statement and actual
cost (DISCLOSURE/SE'ITLE11EN'!' STATEMEN'r - HUD 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 infoDlBtion 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 tilne, assertain if there will be personal property tax on
subject property or an amount on which to b3.se a proration. Any proration necessalY
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.
'IHAT ALL Ul'ILI'lY BILLS (WATER, ~, ELEX:lRIC, M1\IN.lHmNCE FEES) HAVE BEEN PAID
OR WIIL BE PAID UPON ROCEIPr OF FINAL BILLS.
l2iJ /J1(
INITIALS
INITIALS
SEUER'S FORWARDING ADDRESS:
~3 5191 !)_iUL-1~2) 4 ~.
BUYER'S FORWARDING ADDRESS:
HG1E PHONE#
Ha1E PHONE#
M:>RK PHONE#
WORK PHONE#
THIS IS TO FURTHER AU'll-IORIZE
CHANGES NECESSARY TO '!HE CLOSING STATEMENT.
TO APPROVE:ANY
BY:
STEWARl' TITLE <:::a1PANY 'OF CLEARWATER, INC.
Ci7l/~4~ '
17(,- I~( ;f"~ /.f;rar/?--
. / ~j
,..~ BE FILLED IN PERSONALL J
BY SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
AUDREY DIXON MYRICK
Seller or Owner-Borrower
LarS 8,9 and 11, LESS S 50' FOR STREET, 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
A';Jr~te Ar;r;} /11.
.
2. No loans of any kind on said property except the following: (If none, so state.)
NAME AND ADDRESS OF CREDITOR
~roxlmate Al!JPun,~ A
rvt.L /J. Ii{ /1'1.
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 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 MA TERIALS J\pproxlmate A),I1o'Wt,
!,J)v'-e.-- !J.L@J1.
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 the.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 AlTORNErS FEES THAT SAID PARTIES MAY INCUR IN CONNECTION WITH SUCH UNMENTIQNED
LIENS, PROVIDED SAID LIENS EITHER CURRENTLY APPLY TO SUBJECT PROPERTY. OR A PARTTHERE-
OF, OR ARE SUBSEQUENTLY ESTABLISHED AGAINST SAID PROPERTY AND ARE CREATED BY ME,
KNOWN TO ME OR HA VE AN INCEPTION DATE PRIOR TO THE CONSUMMA TION OF THIS TRANSACTION.
Id not purchase same or lend money thereon unless said representations were made.
SWORN f~ A~~ ~UBSCRIBED B.. EFO..RE ME rn:s ! (, r/I
77 ~'&j rY~ t 1. f J1 (1/1
Notary Public i andJor PlNELLAS CountY'F1.ORIDA
day of
DECEMBER
91
,19_.
My Commission Expires:
c; ~;< t/--'1d---
Rev. 1/88
NOTE: Tho fonn I. to be .1....., by IOllor in cale or sale. If no llle. k ill to lie liped loy tho o.........."o....r, If thole I. Iny IItW conllruetion. the contrlctor mull 11.0 join in this form
or liin I separate one.
1
,
SIIII,'/i/.f 01 f.'fllI/",a
RONALD IRON) E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
srrEWAl~rl' rrrl'LE
OF CLEARWATER
P,Q. Bo)( 2756
Clearwater, Florida 34617
(813)441-2689
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 I FOR STRElIT, 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.
~4~
W1tness
--"1:""
Witness'
STATE OF
FLORIDA
COUNTY OF
PlNELLAS
SWORN TO AND SUBSCRIBED BEFORE ME THIS
IbrA
,
DAY OF
DECEMBER
, 19 91.
My Commission Expires: qcJ-{ 1;(
(2.(/'-
~
I
I
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 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.S. Regulations, including the possible
withholding of twenty percent (20%) of the current sales price.
File Number: · 910601110
Taxpayer 10 Number:Seller 1 /J'&-c3~~/5'fD
Seller 2
Taxpayer 10 Type:
2
~1= business, 2 = individual)
SELLER 1 NAME:
MYRICK
Last:
First & Middle:
AUDREY DIXON
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: ~
street: < ~ . ~~
City:.,.${ .;'%~7P
SELLER 2:
Street:
~'~,
state:~.4L.
Zip Code:
337//
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, BRCMNELL SlREET, CLEARWATER, FL 34616
Legal Description:
I
LOTS 8,9 and 11, LESS S 50 I FOR SIREET, BLK 2, MOASE & HARRISON SUB
Under penal ties of perjury, I, AUDREY DIXON MYRCIK
(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 Interna Revenue Service.
Seller - 1 Signature:
. AUDREY DI
Seller - 2 S1gnature:
/ (
Date: Ie!) - / f.t; - 9/
Date:
CLOSING AGENT INFORMATION (to be completed by closing agent)
STEWART TITLE COMPANY OF CLEARWATER, INC.
Name:
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 10 Number1
59-1433918
I
I
NoN- FOItE.LGH CEH'l'U'lCl\T.LOH lJy 1NIH VIIJUl\l.J 'lHl\l~~.:iI;'1~1l01l
1. Scct.ton 1-145 ur lhl1 Il1terllal Hevenue Colle Pl'uv.l.lleo L1lOt (1 In::f\1S[eree I.I[ u Uniled
States real ptuperly inteJ;est lI1uat withhuld lox 1( lhe lrunsferor is IJ (oreiyn lJerson.
2. 111 order Lu l11[UI;I1l lhe tU.1IIs(eteo Lhot wllhhu.Lu.l.IIV uf Lox J.u l1ut teql.llL'eu upun the
l1.ls1XJs.l.U.oll hy AUDREY DIXON MYRICK
of the UIIHetl States 1'en1 property uescrllJeu os fullows:
LOTS 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, OOASE & HARRISON SUB
the unuersignoo transferor certifies and ueclares lJy Ineans of Lhis certificatioll, the
following:
(a) I (We) am (ore) 110t Iloll-residellt a11ell(s) for (Alrposes of United stoLes illCOll1o
taxa t.tOll 011c.1,
(b) r-1y Ullil f.<J States taYPt'llet' idelltifying 1111I1loor(s) (Social Security Number) is/ore:
~ SOCIN.I S~X;UIU'lY NUI'IIJI!;H
AUDREY DIXON MYRICK
II /g~ -3?'-(58'iJ
If
II
"
k) Ny hOllle mklteu9 .-1.0
(utlochetl olkll.tJ.UIIOl l)l.lge .i.f lIecesom:y)
(d) There ore 110 uLhe!: pe.rsollo who hove Oil oWllen3hJp .I.lILercut 111 Lhe ul.JUve-ueucd.Led
pruperty olhor lhall thuse lJeJ;solls set (ol'th obove ill subpawyntllh (lJ).
J. '.l1Ie 1Il1denJJ.YIlcd hereby further cert.lrJ.cs and tlecJ.on!B:
(0) 1 (w~) ul1derstolld that Lhe lAJrchaser of Lhe aoove described properLy inLellus .
lo rely Oil the fotegoit~l represclltal:.J.olls .-1.11 cOllllecl.toll wilh Lhe lIn.l.ted Slules
l"urelgll jllveslmellt in Ueal Pruperly 'fux l\cL. (94 SlaLute 2(,U2 as ulllellded),
(IJ) 1 (wn) ulIdet:f1lUlld lId.s ceru.r.tcaL.l.ull Ilny t;u Lllsc.l.ofletl to Lho l11lotllal Uevellue
Set:v.l.ce by LJ:ollsreree OIKl thot OilY folse statement cOlltoineu 111 L1tls cerUr.tcalloll
lIIay lJo \1I111.l.Sl!od h.y [.l.IIu, .l.I"pt.l.nolllllCllll ut" lx,)th.
Under rX11mlUes of perjury I (we) ueclare I (we) have exonuned carefully Lhla ceJ:t1-
Ucatioll ontl it is Lt"lJe, correct and complete.
L
PINELLAS COUl \ ty
, .
~ d? '7JZ "
AIJD~XON MYRICK ~.
F1..oRIDA
W tneas
,',',
(1his d 1I1t1enL h1USL be retained wltil the end of the fifth taxable year following tlte,l
ta~able year J.11 wltlch the transfer Laltes place).
CONSUJJl' YOUn A'rl'OIlHI!:'l ANlJ/OIt 'l'AX AI)VlSOlt - NO HEPHESl!Nl'A'1'lON on H(!;C(lI1I'-1l!:NU1\'l'lON IS Nl\lJl!: UY
STE.Wl\tt'J.' 'J.'.t'J"-"~ INS'mI\NCI~ L1l'IPI\NY I\NIJ/OH CONCEHNJ.NG '1'1 IE;
U!;Gl\l.l sun;'.I.C.l.l~;NCY ANIJ/on 'l'l\X CONSQUI~'NCI~S Ol;' '11I1S lXJCUNI~N'.l'. YUU Nl\Y IJ~ IH~QUllWJJ TO FILE:
A COpy Ol~ 'l'IIlS Ixx:tR'1Ufl' W.I'l1I 'l'11I~ IN'l'EIlNAIJ IUWI~:NtJl~ SI~HV.lC!.i:. '.I1I1!:SI~ l\lU~ UUI~S'l'.lONS FUH YOUH
^'1'1UnNI~'x' on 'mx ^lJVlSOH.
S'l'Nl'E OJ~
COUtUY O~..
FLORIDA
PINELLAS
1 tll!;ltr~tJy CI:.U'l'U''Y that:. 011 LIIls day, before I"e, on officer tlu1y auLhorized lit Lhe Slate
aforeeaid ontl itl the COIJItt:.y aforesaid to toke aclmowledYlllents, peraonolly ('PlJeore()
AUDREY DIXON MYRICK
to me Imown lo be Lhe pet:BcJnS deacribecl in alld who executed tho [oJ:egoil1g Inslrument
0I1tJ Lhey ocll.llowlrogetl oofo1'e hie that:. they execuLed Lhe name. . _'
' {Il
Wl'l'NI!;SS hlY hand altd officio1 seai in lhe County und State lasL aforesaid L1tls /1, .
of DECEMBER , 19 ';}l . .
llJr~{Cj;fiJ1m;}/~~,. '
NO' HV WUJ.llC . . // ,;
MY ~'IlSS100 IlXPlIIF,$ I '1;{ '1 ~ 9;;(
day
..;; .. ., 1 I
-'
MIS LDI " PAGE 2 OF OMB No, 2502,0265
. PAID FROM PAID FROM
L. SEnLEMENT CHARGES BORROWER'S SEllER'S
FUNDS FUNDS
700. TOTAL SAlES/BROKER'S COMMISSNlN Baaed 011 price I 130 000.00 @ "It= lO.OOO.OO AT SETTLEMENT AT SETTLEMENT
Division ot commission (line 7(0) as follows:
701$ * 7,249.26 10 BLAN-EDWARDS REALTY, INC.
702.$ to
703. Commission paid al setllement * LESS S2750.74 TOWARDS SELLER CLOSING COSTS * 10,000,00
704.
800 ITEMS PAYABLE IN CONNECTION WITH LOAN.
801.Loan Driginalion fee %
802. loan Discount %
803. Appraisal Fee to
804. Credit Re~ort to
805. Lender's inspection tee
806. Mortgage Insurance applicalion fee to
807. Assumption Fee
808.
809.
810.
81,.
goo.ITEMS REQUIRED BY LENDER TO BE PAlO IN ADVANCE.
901. Interest trom to @$ /day
902. Mortgage insurance premium tor mo. to
903. Hazard insurance premium for yrs. to
904. yrs.lo
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance mO.@$ per mo.
1002 Mortgage insurance mo@S per mo. ;~T' -",e:.:" ,. ,~
1003. City property taxes mO.@$ per mo. .. " . . ~ -:.- ~.
1004. County property laxes mo.@S per mo. i~:~~~'~~ ~~~~':~-$~~t~~ ~'
1005. Annual assess men Is (Maint) mo.@S per mo. ~;t~~'. ' ,.~..;".;'
1006 mo@$ per mo. ~. )t;. :.1
1007 mO.@$ ;~~ ,
peL mo. '.
1008. mO.@$ per mo. ~~i m
!^,~ ,~,' ,\10' . ,
"\ T.'
1100 TITLE CHARGES:
1101. Settlement or closing fee 10
1102. Abstract or title search 10 STC * 300.00
1103. Title examination to
1104 Title insurance binder 10
1105. Document preparation 10
1106. Notary tees to
1107. Allorney's fees to 10
(inCludes above ilems No..-
1108. Title insurance 11101) toSTEWART TITLE COMPANY OF CLEARWATER. INC. * 1 2lO.00
/includes above ifems No..- .
1109. Lender's coverage $ .
1110. Owner's coverage S 130,000.00 '!l
1111.
1112,
1113,
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording fees: Oeed $ 43.00 Mortgage $ Releases S 6.00 JUDGEMENT /MYRI Ix 43.00 h 00
1202. Citylcounty tax/stamps: Oeed S Mortgage S
1203. State tax/stamps: Deed $ 780.00 Mortgage $ * 7An.nn
1204. RECORD AFFIDAVITS/CHARLES.' DELORES. JOSEPH JEANETrE
1205. 4 @ 6.00 I:'AMr ?4 00
1206. RECORD SATISFACTION OF JUDGEMEN'iI.10SEPH FREDERTrK nTX()1\1 1 n r;n
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to EVANS lAND SURVEYING POC
1302. Pest inspection to NO!' Rwnr IW<::'T'EJ) OR RIDUIRED
1303. MAILAWAY PREPARATION/COURIER ?hr;.nn
1304. CITY OF CLEARWATER-LIEN SEARCH * r;nn
1305.
1400. TOTAL SETTLEMENT CHARGES (entered on lines 103, Section J and 502, Section K) .1~ nn l? c;,()() t:;()
CEATIFICA TlON: I have carefully reviewed the HUD.l Settlement Slatement and to llle beat of my knowledge and bellel, II Is a true a
thai I have received a copy ot HUO-l Settlemenl Slalement.
. Sellers
prepared is a true and accurate account 01 the funds which _e received and have been or will be disbursed by the undersigned as part of Ihe se<<lemenl 01 this transaction.
... ,- UEC.t!JVJIj~ 17, l~~l
Se!lIemtnt ~enl Date
SELLER'. AND/OR PURCHASER'S STATEMENT Seller's and Purchaser'e signature hereon acknowttdoes hls/lllelr approval ol"x prorations and slgnln.. their underetandlng Ihal prorallons were based on tues tor the preceding year, or eslimates
lor the currenl year, and In the event 01 any change for the current year. all neces..ry adjuatmenll mUll be made between SelI1r and Purcllaaar; IIkewl.. any default In delinquent taxes will be r81mbureed 10 Tille Company by,lhe Seller,
Tille Company. In lis caPlclty, Ie Escrow Agenl, Is and hie bean authorized to depo81t alllunds It ralVIIln thlslranaactlon In any llnandallnstltutlon. whelher a""laled or nol. Such IInanclallnslllullon may provide Tit e Company computer
accounllng and audit eervlces d reclly or Ihrough a separate entity which, II alllllated with TIlle Company, maycllarge llle IInanclallnstltutlon reasonable and proper compensallon therelore and retain any prollls therefrom, Any escrowl..s paid by any
party Involved in this Iransacllon shall only be lor checkwrltlng and Input 10 the computers. but nollor alore..ld accounltna and audit services. Tille Company shall not be lIabls tor any Interesl or olher charges on the earnesl money and shall be under no
duly 10 invest or relnvesl funds held by It al any lime. Sellers and Purchasers hereby acknowledge and consant 10 llledeposlt oIlhe escrow money In IInanelallnslltullons with which Tille Company has or maf have olher banking relallonshlps and furlher
~onsent 10 Ihe relenllon by Tille Company and lor Its alllllates of any and all benellls (Including advanlageous Intern! rates on loans) Title Company and/or Its alllllales may receive from such IInanclallnst.lullons by reason 01 Ihelr malnlenance of said
~9crow accounls,
The parties have read lhe above senlences, recognize thai the recltallons herein are malerlal, agree 10 seme, and recognize Tille Com II r ylng on Ihe I.
~urchalers~~~owert Sellers
uy: l'l'Y 01" CLtJlli.WA'l't1{
rARNINB: It is a crime 10 knowingly make lalse stalements to the Unlled Slales on lhls or any oilier 8lmllar form. Penalties upon convlttion can lnelude a
Title Insurance- Stewart Title
I ~ ~ 2 q - '5-- 5 Y .3,::,r'.~ ())).
rJ 0 f()
See Joanne f/ Charles Dixon
OR 776Z Pg ZS9
Included in same policy/file
~c (\o.(d
M'axine Dixon f/ Audrey Dixon Myrick
OR 776Z Pg Z61
Joanne Dixon Murray f/ Charles Dixon
OR 776Z PG Z6Z
Joseph Dixon
OR 776Z PBG Z63
"
Delores Dixon Wilson
OR 776Z Pg Z6S
Hershell Bobby Dixon
OR 776Z PG Z66
Bettye Dixon Dwight
OR 776Z PG Z67
Jean Dixon Chaney
OR 776Z PG Z68
:,;