DELORES DIXON WILSON
/ 10,'(enclose sell-addressed slamped envelope)
INST . 91-~4??0~
_JID~:~.1 ~ :/. 99:1.'" ~I.":"':l'~;;'ph
91060110 .
Th~ ~:'"~TIl'~;llt W:l:~ prepared b',;
STCW..\HT iTE,E O}' CLEAi;:hT;';i,1l
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This Instrument Prepared by:
(:~::~n.i/~i1(-~:" rL J~~iIi:~';;
~;.n. r\::':. :t75rt
Add'...:
[~-:';"LC.\!,j,~t;:.;: F.l j.-~6( '7
~l/;'~_d~ En:,i:nli'-'~r."r'~ i,~ ~-'. :~.H~~,a".:!'l incit;"nHI'
6:(; ,,':-H:tl:~ ~;r ::; "n:lr ~ n~u:,HH.:o:' t"o~i~y.
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Pd $ Ua.'--
(lcumcntary T<lx . .-,-'
, I"Wqgi~)If} Tax Pd.
Is,k. PiTl8\13S COI!ntV
Deputy Clerk
Property Appraisers Parcel Identification (Folio) Numberls):
Grantee/s! S.S, #[S!:
SPACE ABOVE THIS LINE FOR PROCESSING DATA
SPACE ABOVE THIS LINE FOR RECORDING DATA
f'OTAL
mitts Barrantv I1ttb Ma4e the //3 day of December, A.D. 19
DELORES DIXON WILSON, a.l ~vr L tel woman
hereinafter called the grantor, to
CITY OF CLEARWATER, FLORIDA
whose post office address is P.O. Box 4748, Clearwater, Fl. 34617-4748
hereinafter called the grantee:
(Wh.rev.r used h.reln Ibe terms 'grantor' and 'grantee' Include aU lb. parU.. to ibis lnetrum.nt and lb.
h.ire, I.pi repre..nt.atlv.. and ..eigna of IncIJvJdualo, and !.be .ucc..sore and ..sign. of corporation.)
.ftnelllldlJ: That the grantor, for and in consideration of the sum of $ 10.00 and other
valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises,
releases, conveys and corifirms unto the grantee all that certain land situate in Pinellas
County, State of Florida , viz:
Lots 8, 9 and 11 less south 50 ft. for street, Block 2, MOASE AND HARRISON'S SUB,
PH H-2, Pg. 85, Pinellas County, Florida.
ALSO DESCRIBED AS:
Lots 8, 9, and 11 less South 50 ft. for street, Block 2, MOASEAND HARRISON'S
SUBDIVISION of Lot 7 of R.H. PADGETT'S SUBDIVISION, according to the Plat thereof,
as recorded in Plat Book 2, Page 85 of the Public Records of Hil1sborough County,
Florida of which Pinellas County was formerly a part.
Parcel no. 15/29/15/58338/002/0080 Grantors soc. sec.
91 by
01 RECORD~
REC ~
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\T~ES
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~property is not the principal r i~ nce ~ the
nDd er. with all the tenements, hereditaments and appurtenances thereto b longing or in anywise
appertaining.
arn )faue anb tn )fnlb. the same in fee simple forever.
.Anb the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee
simple; that the grantor has good right and lawful authority to sell and convey said land, and hereby warrants the
title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land
is free of all encumbrances, except taxes f8cruin~ sJ.tbsE:~ent t~ Decemb(~t 91, 1991, . and all easements
)n .Unellll .lJerenf. the saili::'anfo~~a~~?ii-e?f;niseafe7Ft~~se.presents the day and year first abave
written.
delivered in the presence oj:
(.
~1~\)M..~W~.V ItU
DELORES DIXON WILSON
Printed Signature
Post. Office Add~...1 ~\ 21 B ~
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Signature
Signature
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Printed Signature
Printed Signatur<!
CHECK
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Signature
Poet Office Addreoo
Pnnted Signatu",
STATE F FLORIDA
COUNri' OF rI~
. 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, persona]ly appeared DELORES DIXON WILSON , a ~( y')..J,) ciJ"v 0 man
,,""'-" '. to me known to be the person described in and
who executed the...fOl."~goi.ng instrument and she acknowledged before me that J3he .-JI~ecuted the same,
WITNESS. m~ ha,tnd O~~I,J% in the County and State ]88 oresaid ~~y of December"A,D. 19 91.
SEML / ,-::;
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"-'
ignature
'1!,:(c:-.~,~ ~-';'" 3 [lO,I\'::U "
My Comnu"lon Expl,!;;.: I._.J. : .- ~. :__. ~~.... 'lA ~(7~
illf (()mO-::lts:rm t:,?,.~. 1.._, "~.r .,
J aond"d Thtu Troy Fain' l"'Ufan,s ),;.';,
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KARLEEN F. DEBLAKERy CLERK
F:ECClF:I:i ')EF: I F I ED BY:'~
'1-::1
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^ F FlU ^ V I T
STATE OF FLORIDA
CO U N T Y 0 F IX i JQ:ex1xka: xx
BEFORE ME, THE UNDERSIGNED AUTIIORITY, personally appeared
DELORES DIXON WILSON
who being by me first duly sworn deposes and says:
T hat she i s not 0 n e and the sam e per son a s DELORES WILSON
who is named in
welfare liens
as r e cor d e din O. R. U 0 0 k 4366
Page 1574 *** Public Records of Pinellas County, Florida.
*** O.R. BOOK 5105, PAGE 541 and O.R. BOOK 5993, PAGE 1351
Affiant further states that --1ler Social Security Number is as
f 0 1 low s : / r l & '- ~ () -lllJ ~ AND SHE NEVER LIVED AT THE FOLLOWING ADDRESSES:
4526 21st Ave. South, St. Petersburg, Fl.; 493 Jordan Park, St. Petersburg, Fl 33712;
or 414 26th Ave. South, St. Petersburg, Fl. as shown in above welfare liens.
Signed, sealed and delivered
in the presence of:
'~ ~"'.
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DELORES DIXON WILSON .
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S w 0 r n to and sub s c rib e d be for e met his 13 day 0 f December
, 1 9 91
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&y ~~t.te
of Florida
My Commission
expires~~ S Ofi"
, ' ~'I!)hl(V 1.:"''',. lul~ '" .0 "..,
~1:J (llmmissian Expires May 30, ]?S2
.s.-. ~odoci fa 1101 fllio .lnsura"", 11I"'__
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This instrument prepared by:
MIKELL L. ST. GERMAIN
for: Stewart Title Co. of Clearwater
1290 Court Street P.OA. BOX 2756 Clw. 34617
Clearwater, Florida .3461~,
Tel BE FILLED IN PERSONALL i
BY SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
DELORES DIXON WILSON
Seller or Owner-Borrower
LOTS 8, 9 and 11 LESS S 50' FOR S'IREET, BLK 2, IYDASE & 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
APprNimate Amount
t ,/ ~~('
.
2. No loans of any kind on said property except the following: (If none, so state.)
NAME AND ADDRESS OF CREDITOR ,:) Approximate Amount
~\>\f
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 S Ap.,Pfoxlmate Amount
~..1\)~\.A,
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 UNMENTIONED
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.
tl v=
"r-
SWORN TO AND SUBSCRIBED BEFORE ME THIS day of DECEMBER , 19~.
~ 7I~. ~ '''lI6lary'''Lr.;;Sl"..'n.~''''..
6 ~... My Commission EXPirl~'~:~~:::~..~~:.lI12
oIifYPubbc 10 and fo~- County, FLORIDA c1 .... ")tql'
NOTE: This form is 10 be lipod by sellor in .... of ..10. II no ...., it ilto be siped by the _.borrower. If there is any new collllruclion. the contractor must also join in this form
Rev, 1/88 or Ii... a ...pa.... on..
MIS LOt I . PAGE 2 OF OMB No, 2502-0265
. I PAID FROM PAlO FROM
L. SEnLEMENT CHARGES BORROWER'S SELLER'S
FUNDS FUNDS
700. TOTAL SALES/BROKER'S COMMISSION Based 011 prtce I 130.000.00 @ %= 10.000.00 AT SETTLEMENT AT SETTLEMENT
Division 01 commission (line 1(0) as tollows:
701$ * 7,249.26 to BLAN-EDWARDS REALTY. INC.
702. $ to
703. Commission paid at settlement * LESS S2750.74 'IOWARDS SELLER CLOSING COSTS * 1 n IVV", nn
704,
800 ITEMS PAYABLE IN CONNECTION WITH LOAN.
801. Loan Origination tee %
802, Loan Discount %
803, Appraisal fee 10
804. Credit Report to
805. Lender's inspection lee
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 from to @$ Iday
902, Mortgage insurance premium lor mo, to
903. Hazard insurance premium lor yrs, to
904. yrs, to
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance mO@$ per mo, I~~.
1002 Mortgage insurance mO,@$ per mo, ,
1003. City property taxes mO,@$ per mo, "'
1004, County property taxes mo,@$ per mo, lTf" ~
" -'N
1005, Annual assessments (Maint.) mo,@$ per mo,
1006. mO,@$ per mo,
1007. mO,@$ per.mo,
1008. mo,@$ per mo,
1100. TITLE CHARGES:
1101. Settlement or closing lee to
1102, Abslract or title search to SIC * 300.00
1103, Title examination to
1104 Title insurance binder to
1105. Document preparation to
1106. Notary fees to
1107. Attorney's fees to to
(includes above items No.. ;~~ ,. ,
,.
1108, Title insurance (1101) to STEWART TITLE COMPANY OF CLEARWATER INC. * 1 210 . 00
(inctudes above items No,: ..' -,
1109. Lender's coverage $ .
1110. Owner's coverage $ 130,000.00 ~
" ,
1111.
1112,
1113.
1200 GOVERNMENT RECORDING AND TRANSFER CHARGES
1201 Recording fees: Deed $ 43.00 Mortgage $ Releases $ 6.00 JUI:X;EMENT /MYRI "K 43.00 6 00
1202. City/county lax/stamps: Deed $ Mortgage $
1203. State tax/stamps: Deed $ 780.00 Mortgage $ * 780.00
1204. RECORD AFFIDAVITS/CHARLES. DELORES. JOSEPH. JEANE'ITE
1205. 4 @ 6.00 EACG ?4 00
1206. RECORD SATISFAcrION OF JUI:X;EMENT/JOSEPH F'RRnERlrK DTXON Tn t:;n
1300 ADDITIONAL SETTLEMENT CHARGES
1301. Survey to EVANS LAND SURVEYING POC
1302, Pest inspection to NOr STED OR RFnUlRED
1303. MAlLAWAY PREPARATION/COURIER ?f)r;.oo
1304. CITY OF CLEARWATER-LIEN SEARCH "I< c:;oo
1305
1400 TOTAL SETTLEMENT CHARGES (entered on Imes 103,~ectlon J and 502,--sectlon K) Ll':l nn l? ~nn t:;n
CERTIFICA TION: I have care'ully reviewed the HUD-l Settlement Stalement and to!ha best 0' my knowledga and bella'. ills a Irue and accu ~mel all receipts and disburs~deon my account or by m,ln th~ansac~n, I lu;thercertlfy
that I have received a copy of HUD.l Settlement Statement............. , Q ltl 1\, .) .I.' It. ~ ^ \, !\ t':I. ,t--...
oy: C.L'l'Y Ul" CLtAl:{WA'l'lli Dl< J ORE~ DIXON li\ITLSON \ "\.J
Sellars
r are is a true and accurate account of the funds which were received and have been or will be disbursed by the undersigned as part of the settlement of this transaction,
I u.t;C.l:';jVlli.t;t<. 1 /, 1 ~~ 1
Setll.ment A.llent ' Date
SELLER'S AND/OR PURCHASER'S STATEMENT Seller's and Purchaser's signature hereon acknowledges his /their approval of tax prorations and slgnllies their understanding that prorations were based on taxes 'or the preceding year. or estimates
for the currant year. and in the event of any change lor the current year. all nacessary adjustments mUSI be made belween Seller and Purchasar; likewise any default In delinquent taxas will be reimbursed to Title Company by tha Seller,
Tille Company, in its capacity as Escrow Agent. is and has been authorized 10 deposit all 'unds it receives In this Iransacllon In any llnanclallnstllutlon. whether aHlllated or not Such financial Institution may provide Title Company computer
accounting and audit services dlractly or through a saparate entily which. II aHlllaled with Tltlll Company. may charga the f1nanclallnslltutlon reasonable and proper compensation therefore and relain any profits there'rom, Any escrow Ieee paid by any
party involved in this transaction shall only be for chackwriting and Input to Ihe computers. but not lot alorasaldaccountlno and audit services, Title Company shall not be liable tor any Interest or other charges on the earnest money and shall be under no
duty to invest or reinvest 'unds held by It at any time, Sellers and Purchasers hereby acknowledge and consent 10 the deposltollhe escrow money in flnanciallnstitutlons with which Title Company has or may have olher bankln relalionshlps and 'urther
consent to Ihe retention by Title Company and lor its affiliates 01 any and all benellls (Including advantageous interest rales on loans) TItle Compa dlor its alllllales may receive 'rom s inanclal institutions by reason Ihelr maintenance 0' said
escrow accounts. ~ _
Th. partIes have read the above sentences. recognize thatlhe recitations herein are material. agree to same, and recognize Tille Compa~s
p~:~~e~~!?yrer~!,!,y or' CLtAl:{WA'l't;f{ __ Sl1~_'___
"
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\'(#",'t;ty ,II (:o,,',nrt
RONALD (RONI E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
s~rEWAII~r ~rrrLE
OF CLEARWATER
P.O. Bo)( 2756
Clearwater, Florida 34617
(8131 441-2689
AUTHORIZATION AND ACKNOWLEDGEMENT FORM
Reference:
FILE NO.
91060110
LEGAL
LarS 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, MOASE &
HARRISON SUB
SELLER
DELOP.ES DIXON WILSON
CITY OF CLEARWATER
BUYER
We hereby approve and acknowledge receipt of a copy of the Statement, and actual
cost (DISCLOSURE/SETI'LEMENT STATEMENT - HUD FORM 1) and authorized disbursement
of funds as shown therein this 17 day of DECEMBER , 19 9~ 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 Clea:n...."ater, Inc., will not be held
responsible. It is further understood that Stewart Title Cornp2111Y 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 Con~y Company of Clearwater, Inc.
Stewart Title Company of Clearwater, Inc., will be not held responsible.
'IHAT ALL UITLITY BilLS (WATER, SEWm, E:LFOlUC, MAlNI'mANCE FEES) HAVE BEm PAID
OR WILL BE PAID UPON REX:EIPr OF FINAL BilLS.
~
lNITIALS
lJfiTIALS
J2;,J,_tJ ~ 1 ...~:r)~~~~I.>v...
DELORES DIXON WILSON
SELLER I S FORWARDING ADDRESS:
V" ~,~, ~ \:\ 1 ~ \
-
..-~'>0. \10, ~\ ~~l. ,\ '\
HCl1E PHONE#'(Ol D II J 4~ ~ - \ ~J.", ~
"\r\DRK PHONE# /'
BUYER I S FORWARDING ADDRESS:
Ha'1E PHONE#
WORK PHONE#
THIS IS 'ro FURTHER AUTHORIZE
CHANGES NECESSARY TO 'llIE CLOSING STATEMENT.
TO APPROVE 'ANY
STE.WAR'f TITLE COMPANY OF CLFJ\RWA'fER, INe.
BY:
I
I
NON-FOlm.LGN CEH'l'lF'lC^,l'.LON BY INIJIVIlJU^L TIU\NSI;'EHOH
1.
SecU.oll 1145 or Lhe InLernal Hevenue Cooe pt:oviues Lhnt a Lrd\lSferee (I[ a UniLed
StaLes renl properLy interest JlJust withhold Lox if Lhe transferor is (j foreigll ~rson.
2.
In order to 111[01:111 the tnJlJs[eree L1~l:. wlLhho.ldlllg o[ Lox Js 110t requhed upon Lhe
d.ts[XJsJ.L.i.on by DELORES DIXON WIL ON
of lhe Unlled States real property uescdbed as [ollows:
LOTS 8,9 and 11, LESS S 50" FOR STREET, BLK 2, MOASE & HARRISON'S SUB
the undersigned transferor certifies and declares by means of this certification, the
followillg:
(a) I (We) am (are) not 110n-resident alien(s) for p.1rposes of United States incolne
laxat.i.on ond,
(b) My Unil cd Slates toypoper identifylng Illllllber(S) (Social Security Number) is/are:
Nl\ME SOC1.1\L S~-;CUlurlY NUJIIUI!.1t
DELORES DIXON WILSON
,,0/ \ \ ~ - ~~ - ~ \ \.1
ff
II
II
(c) My home mklreos Js
(u tlochc<.l o<..klJ HOllol page .i.f lIecessary)
(d) There ore no oLher persons who hove 011 ownershJp JIILeL'est in lhe nlXlve-descr.i.h?d
property othor tholl lhose persollS set forth olJOve ill subparagraph (b).
J. 'HIe llnders:i.gned hereby rUL"ther cert.tries Old declares:
(a) I (We) understond that the purchaser of the above described property intends
to r.ely 011 the ro'~egoing r.epresentaU.ol1s :1.11 cOl1llect.i.on with the lIn.l.t-,ed States
("oreJ.glI Investment ill Heal Property 'lux ^ct. (94 Statute 2G02 as omended).
(b) .I. (wn) ulldet:EJLund tlds cerlJ.f.icat.l.oll 1I0Y I~ tllsG.1.oEJed to lIm Internal Hevellue
Serv.i.ce by transferee anu that any false statement contained ill this cerUUcalion
lI1ay he! 11I1I1.l.Slt(!(1 by f.l.llH, .I.lI1pdsonll1ont ut" both.
Under POilU 1 ties of
fica lion and it is
,:)
.,.
Da te DECEMBER l ~
perjury I (we) declare I (we) have exallutled carefully this cerli-
true, correct and complete.
1991 ~t"" I\\u~ OJullly, f1DRIDA
~ -4\.d~4\.j-~~~~
DELORES DIXON WILSON , '.,', .
v
Witness
('lhis document must be retained wll:.il the end of the fifth taxable year following the ,,I
taxable year in wh.lch the transfer takes place).
CONSUJJl' YOUH J\'l'l'OHNI!:Y J\NIJ/on 'l'1\X J\DVlSOn - NO HEPHESE.N'IWI'lON on HEC()(\1r-1ENDNl'lON IS fvWJE UY
S'l'E.WI\H'J.' 'J.'.t'JH~ INSUHJ\NCI~ CCNPl\NY ^ND/OH CONCEHNJ.NG '1'1 m
J..EGl\lJ SUn~JC1ENCY 1\NIJ/OH 'J'1\X CONSQUI~'NCES Oli' '11118 OOCUl\mN'.l'. YOU M1\Y BE HEQU.lHl!JJ '1'0 nLE
1\ COpy OF' TiltS IXX:tJI\1JiNl' W.I'L1I '1'1 II~ IN'1'EnNl\r~ IUWEJIIUI~ SI~HV.tCE:. '.I1I1!:SI~ 1\1U~ QUI~S'l'.lONS FUH YOUH
1\'1TOHNI~Y Olt T1\X 1\lJV loon.
"
,',',
S'!'J\'!'E OF \., FLORIDA
COUNTY O~""'" -11-1 ft<-/l(,U&j
I IIEIU!;OY C~~lrl'IL;Y that 011 tltls day, before lIle, an officer duly authorized in the state
aforesaid and in tlte County aforesaid to take aclmowJ.eclgllJents, personally nppeared
DELORES DIXON WILSON
to me Imown to be the persolls described in and who executed Lhe foregoing .i.nstrlUllent
and they acknowlooyed lJefore lIIe that:. they executed the same. ')
WITNESS my halld and official seal in the County nnd State last aforesaid lhJ.;- /3 day
o~ D>=mER , 19 91 , ik 7//Ly
. /I' ('" .. n \ NOl'l\RY PUUJ.,IC ~o'ary Pu~1t(, Stal. 0' "orferer
:l MY CC1'1'lISSION EXpnmlt. Commission Expires May 30, 1992
IDnded TIvu Troy fain -Inaurance Ine.
. '
.., ..
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 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:
91060110
Taxpayer ID Number:Seller 1 ~I \ ~ -.:AD~~\\~ Seller 2
Taxpayer ID Type:
2
(1 = business, 2 = individual)
SELLER 1 NAME:
WILSON
Last:
First & Middle:
DELORES DIXON
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: \)
Street : v"'" . tJ \
City: \j\j ~~ ~ \J
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State: '\-\
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Zip code:~:1 Le ~ \1
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 BRCMNELL S'IREET, CLEARWATER, FL 34616
Legal Description: LOTS 8, and 11, LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON SUB
Under penal ties of perjury, I, DELORES DIXON WILSON
(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:~I, '_' 1~1 I ~ q L Seller - 1 si9oature~\_h'Ii"V~14"" I,,~~Q,. "'v-..
DELORES DIXON WILSON
Date: Seller - 2 Signature:
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE CCX\1PANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 10 Number:
59-1433918
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RONALD (RON) E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
Sr.t....EW AI~ r.t." TrrI~E
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
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.
dvPY ~-
Witness
I~~~~~~~\k\~
DELORES DIXON WILSON
~~L~CU:~ .-&~..
tness '
STATE OF
FLORIDA
~
COUNTY OF
'f
SWORN TO AND SUBSCRIBED BEFORE ME THISV'" ;.3
DAY OF
DECEMBER
, 19 91 .
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My Commission Exp1res:
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otary Public
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