JEANETTE DIXON HAMILTON
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So,,,'tit.. 'I{ t.'",.,,,,,"t
RONALD IRONI E. SOMERS
President
1290 Court Street
Clearwater, Florlde 34616
S'l~E"VAII'r 'rITLE
OF CLEARWATER
P.O. Box 2756
Clearwater. Florida 34617
18131441-2689
AlJ1'lJORIZATION AND ACKNOWLEDGEMENT FORM
Reference:
FILE NO.
91060110
LEGAL
SELLER
JEANEITE DIXON HAMILTON
rms 8, 9 and 11, LESS S 50 I FOR STREEiI', BLK 2,
MOASE & HARRISON SUB
BUYER
CI'IYOF CLEARWATER, FLORIDA
We hereby approve and acknowledge receipt of a copy of the Statement and actual
cost (DISCLOSURE/SETl'LEI'1ENT STATEMENT - 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 made in this
proration when the tax bill is received, it will be handled l:€tween the rlClI~ties of
this transaction. Stewart Title Company of Clearwater, Inc., will not be held
responsible. It is further understood that Stewart Title Compmy 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 p;lrties to this
transaction, outside of Stewart Title Company Company of Clearwater, Inc.
Stewart Title Company of Clearwater, Inc., will be not held responsible.
THAT AIL UITLITY BllLS (WATER, SEJmt, Er..I!X:.lRIC, Ml\:lNI'mANrn FEES)
OR WILL BE PAID UPON REX:EIPl' OF FINAL BllLS.
$
HAVE BEEN PAID
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:J~ili:fk~ vkh ~
JE1\NEITE DIXON HlIMILTON
SELLER' S FORW~ H-,s:
o Y6' 1/117 flfYe
BUYER'S FORWARDING ADDRESS:
Ha1E PHONE#
HOOE PHONE#
~RK PHONE#
WORK PHONE#
TIUS IS TO F1JR'l'HER AU'llIORIZE
OIANGES NECESSARY TO '!HE CLOSING STATEMENr.
TO APPROVE;ANY
.. 1\R1' TITLE C<l'1PANY QF CLEARWATER, INC.
Lo
1,.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
JEANETrE DIXON HAMIL'ION
Seller or Owner-Borrower
LOTS 8,9 and 11, LESS S 50' 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 ~
Appr~lmate Amount
./1'L-'b-1~ /
.
2. No loans of any kind on said property except the following: (If none, so state.)
NAME AND ADDRESS OF CREDITOR (){)-X AP~~1U ~'Yount
r
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 f lI~paid and satisfied, except: (If none, so state,)
NAME AND ADDRESS OF SUPPLIER OF L 0 "f ,VICES OR MA TERIALS A~~~~&ount
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 A rrORNEY'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 thereon and would not purchase same or lend money thereon unless said representations were made.
~~E D~HAMIL~ t;;
A A11llv 0mJ Afl. 'E
S ORN TO AND SUBSCRIBED BEFORE ME THIS / Zl .
day of
DECEMBER
91
,19_.
/Ii \... _
County, FLORIDA
My Commission Expires: 1;;; ( .qv J-.
Rev, 1/88
NOTE: ni, form I, 10 hr ,Ipod by telltr in cate of lilt. If no llle, it illo lit ,Ipod by Ihr o.....r.bo"o'Wr, If Ihrre illny..... con.truction. the conlrlctor mUll 11.0 join in this form
or lian . .IMraae OM.
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Sf/lldil'y ,,/ {;()lIlnrrt
RONALD (RaNI E, SOMERS
President
1290 Court Street
Clearwater, Florida 34616
S~I~EW AI{~r 'rI'l~LE
OF CLEARWATER
P.O. Box 2756
Clearwater, Florida 34617
(8131441-2689
D I S C LOS U R E
We, the Owners of that certain real property located at
wrs 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.
IV/ L(l/----
STATE OF
FLORIDA
COUNTY OF
PINELLAS
SWORN TO AND SUBSCRIBED BEFORE ME THIS
/7 tfi'
DAY OF
DECEMBER
, 19 91
My Commission Expires: 1-;;Jrj-'t;L
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NON-L;'Olm.lt.;(1 CEn'l'H'lC^T.lOH In HIIJIVIIJU^IJ '1Hl\W.:WEnOll
1.
Sect.loll 1-115 or l"{~ llllenlal Hevellue Coue pt"uv.\.uen L1lat n tt-il\,sfeJ:ee ','[ a United
States real properLy illte):eat lIluat withhuld Lox lr lIle LL'allsferot' is /J rorely" lXn"SOIl.
2.
111 ord(!I: tu 111[01.\1\ LIte tnUls[eree Lhot wiLhhuhll.lIg of Lox 1u nut requited upun Lhe
cllsposJ. U.OI1 hy JEANEITE DIXON HAMILTON
or Lhe UlIlLed SLoLes 1'eol l'L'Operty uescdbed os [ollows I
LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON SUB
wrs 8,9 and 11,
tha ulldersigned transferor certifies and ueclm:ea Uy IlIeana of LIlla certification, Lhe
folluwillg:
(a) I (We) am (are) 110t HOIl-reaident ol1en(s) (or l:A.U:poses of United StoLes illcollle
Laxo t.tUII 011(1,
(b) ~1y Unil r..u SLates Laypnpe.t; identifying lIullIber(a) (Social Securily Number) is/an~:
Nl'l'1E SOCJ.^,J SITCUlU'l''i NUf'IIJEIl
- JEANEITE DIXON IWIILWN 9 C{ G J - 3 '-/ -: :)'t, :;7>
ff
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(c) Ny hOllle mklreu9 18
(u llochetl atklJl1.ullol lJUge .i.f lIecessOJ:y)
(d) There ntc 110 oLhm: parsoll::J who hove UII OWIIC):SItJp .I.lILeresL 111 Lhu uIJUve-ueucd.bed
pruperLy oLhr:1r 1I1Cl1I lhose 1)01:801lS set (orLh obove ill sublk-u:ogwL,h (b).
J. 'JlIa \lJldersJglled he,reby [ut"ther cerLlrJea ond tleclat-es:
(a) 1 (Wo) ul1uerstunu that tha l~t'chaser of the above described property intenus .
lo ,:ely on the fotegoinu r.epresentaUons 111 cOllllect.toll with Lhe lIn.l.l:ed Stoles
l"ureJglI Illvcstlllellt ill Heal l'l-ol,>etLy 'riO{ 1\cL. (94 Slolllte 2GU2 as wllcllc1ed).
(IJ) J (WO) UlldetAtund lids cetU.r.tc~lt.l.olI IlrJY IJa tllsGlosed Lo lIm llllotlla.l HeVellllC
ServJce by lr:ons(etee olKl that ony (also EllotelllellL contained in 1I1ls cerlJ.Ucallul1
llIay Ix! Plln.l.slt(!t 1 hy [.1.1 It!, l"'pt .l.BolllllOIlt UI: hoth.
Untler rX~I\t)llies or perjury 1 (we) ueclare I (we) have exall\ille{] carefully this Cel"t1-
ficatioll onu it is lnJe, correct ElIIU complete.
DECEMBER
PINELLAS
County,
FLORIDA
fJ
W t ess
(11 is document:. hlJst be retained uIll:.il the end of the fifth taxable year following Lhe,'
taxable year 1n wh.Lch the transfer lakes place).
CONSUJJl' YoUn NrlUIlNI!:Y 1\NIJ/on 'l'1\X 1\IJVIS0n - NO llEPlU~E.N'1'1\'1'lON on llECO\I"'ENU1\TlON IS N1\\)1!: UY
STE.W/\It'J.' 'l'l'JU~ INSUU/\NCI~ Ol'1Pl\Ny 1\NlJ/on CONCEHNING TilE
U:;G1\IJ sun;'JC.l.l~:NCY 1\NIJ/OH 'J'1\X CONSQUI!1-ICI!:S Oli' '11I1S lXX.'UI'1I~i;:--Your;;^y BE H1~QlJlmU TO nL8
1\ COpy Ol~ 'I'll W Ixx;tJMUfl' W.I'l1I '1111~ IN'l'El~N1\fJ H1!.VI!:NUI~ SgHV.lC~:. '111\!:SI~ /\H1~ UUI~Sl'.lONS FOlt YOUH
^,l'l'OnNIW on '1'1\K. ^,JV1S0H.
f)vwte:fl0uJ ~,~
;JEANETTE DIXON HAMIL;. N.' . . :,',' .
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S'l'l\'l'E Ol~
COUNTY Ol"
FLORIDA
PINELLAS
I IIEIU~fJY CI!:H'l'1l''Y that 011 lItls day, before Ine, on officer uuly authorized in the SLate
aforesaid and itl tlte County of;oresaid to toke aclmowledYl1lents, persol1ally nppeared
JEANETTE DIXON HAMILTON
to me Imowl1 to be the lJetslJI1S uescribed ill anu who executed tho foregoillY lnstnllllellt
onel they oclmowlwye{] lJefore hie that they executed the sallie.
WITNESS my hOll{) and official Beal ill the County und Stale lost aforesaid L1d.s /7 ' dtlY
of DECEMBER , 19 ';)1
NO "It\, roUl_,J.C
MY Cal'lISSION EXVIHli;SI 9J01.~
f
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INFORMATION FOR REAL ESTATE l099-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 ID Number: Seller 1 J..~ j.- 31-06 ~-b
Seller 2
Taxpayer rD Type:
2
~1= business, 2 = individual)
SELLER 1 NAME:
Last:
HAMILTON
First & Middle:
JEANETTE DIXON
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1:
Street:
City: '
State:
rL-
Zip Code:
l3/~ f5
SELLER 2:
Street:
city:
TRANSACTION INFORMATION
State:
'Zip Code:
Closing Date (MMDOYY):
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 STREET, CLEARWATER, FL 34616
I
Legal Description: LarS 8,9 and 11, LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON SUB
Under penal ties of perjury, I, JEANETI'E DIXON HAMILTON
(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 r understand that it will appear on a For~
1099~S that will be sent to me and to the Inte~n~l ReVenUj ~ervice. ~
Date: /iJ /;1/1/ Seller - 1 Signature~ #4l4>1df---
JEANETTE DIXON HAMILTON
Date: Seller - 2 Signature.
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE CQI1PANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
Taxpayer ID Number1
CLEARWATER
State:
FL
Zip Code:
34616
59-1433918
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A F r I U A V I T
STATE OF FLORIDA
COUNTY OF Pinellas
BEFORE ME, THE UNDERSIGNED AUTIIORITY, personally appeared
JEANETTE DIXON HAMILTON
who being by me first duly sworn deposes and says:
,J
That
SHE is not one and the same person as
JEAN HAMILTON
who is named in Welfare Lien
a s r e cor d e din o. R. Boo k 3980
Page
353
Public Records of Pinellas County, Florida.
A f f i ant fur the r s tat est hat her So cia 1 S e cur i t Y N u m b e r i s a s
follows:
sealed and delivered
resence of:
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/ .it~~
.: J~ DIXON HAMILTON .
S w 0 r n to and sub s c rib e d be for e In e t his 17th day 0 f December
, 1 9 91
'/.~u
N tary Public, State of Florida
My Commission expires: c;;;!7d
This instrument prepared by:
MIKELL L. ST. GERMAIN
for: Stewart Title Co. of Clearwater
1290 Court street P.o. Box 2756
Clearwater, Florida .346g. 34617