JOSEPH DIXON
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'\"",'I;ly of CHII,rttrt
RONALD IRON) E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
S'l~E'V Al{'r 'l~I'rl-,E
OF CLEARWATER
P.O. Box 2756
Clearwater. Florida 34617
(8131 441.2689
AlJnIORIZATION AND AO<NCMLEDGN'1ENT FORM
Reference:
FILE NO.
91060110
LEGAL
LarS 8, 9 and 11, LESS S 50' FOR STREET, BLK 2,
SELLER
JOSEPH DIXON
IDASE & HARRISON SUB
BUYER
CITY OF CLEARWATER, FLORIDA
We hereby approve and acknowledge receipt of a copy of the Statement. and actual
cost (DISCLOSURE/SE'lTLE1'1ENT SI'ATEMEN'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 infonnation available. If any changes are to be !Tude in this
proration when the tax bill is received, it will be handled 1:-etween the parties of
this transaction. Stewart Title Company of Cleanvater, 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 wili be handled between the parties to this
transaction, outside of Stewart Title Company Company of Cleanvater, Inc.
Stewart Title Comp:my of Clearwater, Inc., will be not held responsible.
'IHAT ALL UITLITY Bll.LS (WATER, ~, EUX:lRIC, Ml\INI'EJfANCEFEES) HAVE BEEN PAID
OR WIlL BE PAID UPON REX::EIPr OF FINAL Bll.LS.
INITIALS
SELLER'S FORWARDING ADDRESS:
BUYER I S FORWARDING ADDRESS:
HCX\1E PHONE#
HQ'vIE PHONE#
\AK)RK PHONE#
WORK PHONE#
THIS IS TO FURl HER AU'llIORIZE
OlANGES NECESSARY TO '!HE CLOSING SI'ATEMENr.
:!'Q APPROVE; ANY
STE.WARf TITLE COMPANY 'OF CLEARWATER, INe.
BY: Cff(l~})ddbj~
TolaE FILLED IN PERSONALL vi
BV SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
JOSEPH DIXON
Seller or Owner-Borrower
LOTS 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:
l. 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 Approximate Amount
2. No loans of any kind on said proP91
NAME AND~ D~SS OF CREDIT _ C
"
II
I'
.
except the following: (If none, so state.)
Approximate Amount
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 h~ve be~-fully paid and satisfied, except: (If none, so state.)
NAME AND ADDRESS OF SUPPLlE~~F L~Jl6R, SERVICES OR MA TERIALS Approximate Amount
1~d'YLc? ~<~L
//
"
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
5. 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 th~.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 HA VE AN INCEPTION DATE PRIOR TO THE CONSUMMATION OF THIS TRANSACTION.
I realize that the purchaser and/or lender in this transaction are relying on the representation contained herein in purchasing
same or lending money thereo d would not purchase same or lend money thereon unless said representations were made.
/ vzuf. t.--
J SEPH DIXON
SWORN TO Ar S~BS,C~I~~D BEFORE ME THIS
-or
/7 day of
DECEMBER
91
,19_.
My Commission Expires: q dc/~ '1 J
Rev. 1/88
NOTE: Thil form it to be lianod by ..ller in .... of ..Ie. If no ..Ie. il is to be oiped lly the owner-borrower. If .here it Iny new conllrllClion, Ih. conlrlClor mUll 1110 join in thit form
or li.n I .p.,ate one.
1
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,"l"",r'til.Y "I ('(JlIlI"llrl
RONALD (RON) E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
s~rEWAI{'I'I ~rrl'1LE
OF CLEARWATER
P.O. Box 2756
Clearwater, Florida 34617
(8131 441.2689
D I S C LOS U R E
We, the Owners of that certain real property located at
LarS 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.
W
~.. 0JdM/L~
W . t es s
STATE OF
COUNTY OF
F1.ORIDA
PINELLAS
.7d
SWORN TO AND SUBSCRIBED BEFORE ME THIS / -
DAY OF
DECEMBER
, 19 91
.~
My Commission EXPires~ df 7':J
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'.,
NUN-l;'UIH~lGH Cl:;H'l'.lflCJ\TI0H IJY HIIJ.l.V IlJUM, 'lH1\W.:irEIlUH
1.
SecU.Ull It'''5 ur UIO IIlLerllal Ilevenue Cuue pruv.l.uen Umt (1 tni\lsfel-ee '.I[ a United
states real pt.uperty interest II1USt wlthhuld Lux ir Lhe LUlllSfet.ot' is IJ [ot'ei~Jll persoll.
2.
J.n order Lu 111[U1.l1l Lhe Lnlllsferee Lhut wiLhhu.ldJ.lIV o[ Lox Ju nut reqllireLl lllXJI1 Lhe
tl.lspos.l. t.l.OIl hy JOSEPH DIXON
of the UlIlletl Slotes renl property uescr.lbeu os [ullows:
LOTS 8,9 and 11, LESS S 50 I FOR STREET, BLK 2, MOASE & HARRISON SUB
the ulluersiglletl transferor certifies alld declares by llIeans of litis certification, lhe
following:
(a) 1 (We) alll (are) not I)oll-residellt ol1en(s) for p.lI:(XJses of United Slotes illcome
taxat.loll 011(1,
(b) F-1y Unil r..{) Stotes toypapeJ; identifying lllllllber(S) (Social Security Number) is/ore I
NJV.11!: SOCIM.I S~X:UIU'l'Y Nl/I'lIJl:;1l
JOSEPH DIXON
II 2 ~6 .5'Y Y } . ~5~ f/ ~
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(c) r-1y hOllle n<.klnm9 J9
(utlodloo otldJU.ollol IXlye :f.r lIecessm:y)
(d) There ote 110 oLher parsulls who hove UIl OWlleJ:uhJp Jlllere9t ill Lhe ulXJvo-uoucr.l.ood
pruperty oLh8r thall lhuse l)OrGolls set fotoUI ol.XJve 111 sulJpat;.oYlTIplt (LJ).
J. '.l.1Ie llJldersJgned he.teby fUt.ther cert.lfJ.es OlkJ declares:
(a) I (Wp.) understDlKl that the p.lrchoser of Lhe above uescribed properly illlellus .
lo rely 011 Lhe [otegoi1l9 r.epreselltatJol1S JI1 c0I111ecL1011 wIlh lite Ihl.1.ted SloLes
(l'urelYII Invesllllellt ill Heal Properly Tux 1\cl. (91 Slatute 2GU2 us Wllclldetl).
(IJ) .I. (WO) UII<.!et:nlulld L1d.s CetlJ.f.Lcal.l.uII 1I\]'y IJU tllSG.l.ose~l to Lho lllLoUlal Hevcllue
Ser.vJce by trollsferee alld thnt OilY folso ElLnLell1enL contalueu in lhls cetUr.h::aUoll
llIi.IY lJo l.lIl1l.1.(;lh(!c1 hy Ll.lI(~, .l.IIlPt.l.BOlllllOlll Ot. both.
Untler l)(Jllu1l1es of perjury 1 (we) declare 1 (we) have exomilletJ carefUlly lI11s certi-
fication Old it is It-ue, correct atld cumplete.
1991 at
PI~~ ~lY' :r-ORIDA
~.ON'
W tit 88
(1h dOClDTlent h1ust be retained Wll:il t.he end of the fifth taxable year following the,'
taxa Ie year 1n wlt.tch the tran8fer takes place).
CONSUJJl' YOUn 1\'l"JUIlNlrl 1\NlJ/on 'l'J\X 1\1)VlSOn - NO HEPltESI!.N'l'1\'1'lON on UOC(XIi'IENlJl\'1'lON IS Nl\lJ~ Uy
STE.W1\tn' 'l'l'J'IJI~ INStJH1\NCI~ C()l1I,J/\NY 1\ND/OH CONCI~HNJNG Till!;
U~G/\I.I SUH~JCJtNC'i 1\NIJ/OIl 'l'/\X CONSQUI!.'NCI!:S m' '11IJ.S I.XJCUI'1I~til'. YUU N1\Y 1Jl!; HEQUlmU To 1;'lL8
1\ COl'Y Ol;' TillS J)OCtJMUfJ.' W.I 'L'II '1'I11~ IN'l'E1tN/\r~ H1W~;NtJl~ SlmV.lCI!:. 'lll1!:Sl~ /\IU~ UUI~SJ'10NS lron Yaun
/\'1'lQnNl~'i on '1'/\X /\IN loon.
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S'l'/\'1'E Ol~
county m1
FLORIDA
PINEILAS
I 1I1!;1U!:UY cl:.ln'll''Y that on Llt.La day, before tne, an officer duly authorized in the Slate
aforesaid and itt the County oforesaid to taka aclttlowJ.eclYlllents, lJersonally nppeored
JOSEPH DIXON
to me known to be Lhe persons described in Bnd who executed the foregoing 11lstnllllellt
anel they ocktluwlroyeu Lefore hIe thaI:. they executed the sallie. . '_ LA.
WI'1'NESS my hOllo and official seal in the County (Jlld State last aforesaid tillsi' 7 . , uny
of DECEMBER , 19 ~1 · lz .
.. ~ 'tllfY ~J~~
NO ~H,{ PUUI~ 1... 'lLf' C;''')
M CaJlUSSION EXl'lIU~ l C::J. 1'- 7 c:I-
I
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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 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.x 2-;; > 3--8.3 jrrJ.f Seller 2
Taxpayer 10 Type:
2
~1= business, 2 = individual)
SELLER 1 NAME:
Last:
DIXON
First & Middle:
JOSEPH
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1:. / / ~:-.?-
street: X !/051 tJ-cJlL/A' J (
city: ~/ H" state:
Zip Code:
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, ERa-JNELL S'lREET, CLEARWATER, FL 34616
Legal Description: LOTS 8,9 and 11, LESS S 50' FOR S'IREET, ELK 2. MOASE & HARRISON SUB'
Under penal ties of perjury, I, JOSEPH 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 Re~enue s~vice.
Date: ))1.1-1;;7-9'1 Seller - 1 Si9nature:~ONU~
Date: Seller - 2 Signature:
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name: STEWART TITLE C'G!PANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 10 Number':
59-1433918
. .
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^ F FlU ^ V I T
STATE OF FLORIDA
COUNTY OF Pine1las
B E FOR E ME, HI E U N D E R S I G NED ^ U THO R I T Y , per son all yap pea red
JOSEPH DIXON
who being by me first duly sworn deposes and says:
.j T hat HE i s not 0 n e and the sam e per son a s JOSEPH D. DIXON;
JOSEPH A. DIXON; JOSEPH DIXON and
JOSEPH AUGUSWS DIXON who i s n a m e din liens and judgments
a s r e cor d e din O. R. U 0 0 k 4698
Page
1032 **
Public Records of Pine11as County, Florida.
A f f i ant fur the r s tat est hat his So cia 1 S e cur i t y N u m b e r i s a s
** O.R. Book 6570, Page 1622, O.R. Book 7153,
fo1 lows: Page 2335, O.R.Book 7310, Page 870, O.R. Book
7324, ~age 1840 and O.R. Book 7325, Page 1942
Signed, sealed and delivered
in the presence of:
~=~
Sworn to and subscribed before me this 17th day of December
, 1 9 91
.~
ary Public, State of Florida
My Commission expires: tl?;lt/'.9d
This instrument prepared by:
MIKELL L. ST. GERMAIN
for: Stewart Title Co. of Clearwater
1290 Court Street P.o. BOX 2756,
Clearwater, Florida .3461G.':.34617--