HERSHELL BOBBY DIXON
INST I 91-342286
'R~lurn 10: (o'nclo... .ell-addlessed .tamped envelope) I... D ~~:; , ~1:!=1~~_ ~~~? ~, 1 : 49 Ph
Name: : 91066'.1....0
j This Inslnlln:n' ""1, .:)r':.,~""; '"
f) n'~ :;:E~~~~~L.J,~~~q~1AIN
P U';'HC(':;,;"l:
This Instrument Prepared by: Clearw9Ic,. Fl.
Add,...:
rsJ \~
Add,...:
PINELLAS COUNTY FLA.
I 0 F F · I.::.n~.:: C. +. 1.'{ I'::. ':? -:;' ,':.. ') ./.:, I':',' ..
" . ..' -......... -.. :.;.::<S6
----. -,,-- '------._-
p.o. f;tn: 1.7~~1
ClurWMler, FL J36ji
Which In~trument ~as prep:ucti ir.,>, 'CJ
to writing of II Titk InSllrUla 1".,1'
uOo)
Intangible Tax Pd.
b:,. Pin,,1I3s County
__ D:Jput'{ Cleric.
SPACE ABOVE THIS LINE FOR RECORDING DATA
Doc mentary Tax Pd, $
$
Property Appraisers Parcel Identification (Foliol Number!s):
Grantee[sl S.S. #[sl:
SPACE ABOVE THIS LINE FOR PROCESSING DATA
B
(fEES
~'lcrI';
('/e
REV
TOTAL
Kor
~~ ~~~~~~!t, ~~e~, ~~t 'man December,
hereinafter called the grantor, to
CITY OF CLF.ARHATER, FLORIDA
whose post ofjice address is P.O. Box 4748, Clearwater, Fl. 34617-4748
A.D. 19 91
by
c.0
hereinafter called the grantee:
(Wherever uaed herein the terms .grantor" and .grantee. In.lude all the parties to this ill8trum.nt and the
bei..... legal repre.entativeo and as.igne or Individual.. and the .u.....o.... and assign. or .orporation.)
Bftne.ll.lldlJ: That the grantor, for and in consideration of the sum of $ 10.00 and other
valuable considerations, receipt whereof is hereby ackn(YU)ledged, hereby grants, bargains, sells, aliens, remises,
releases, conveys and confirms 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,
PB H-2, Pg. 85, Pinellas County, Florida
ALSO DESCRIBED JlS:
Lots 8, 9, and 11 less South 50 ft. for street, Block 2, MOASE AND 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 Hillsborough COlillty,
Florida of which Pinellas County was formerly a part.
Parcel no. 15/29/15/58338/002/0080 Grantors soc. sec. II e ,,-,5-56- b L/12
Property is not the principal residence of the Grantor, he in fact(~~r~L&t:
r/5t3(.,J 8(1: 1N,,- !\)E.tJVt? K. /(J' 52 t#-/l,eJ
o,tt et. with all the tenements, hereditaments and appurtenances thereto belonging or in anywise
appertatning.....
\
ato )fane anb to )lolb. 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 accruing subsequent to December 91, 1991,. and all easements
)n Bftne.ll.ll BlJereof. the saillWaJlb~ha}~t~~~1tna~eafea~h'e1e presents the day and year first above
written.
Si7\ed, sealed and delivered in the presence of
" L/()^.J/v~ D, .,t.}4-/ /
Si~.. wicness III
, ~<-&IL."7f. ~,_ 7J..JtH
Printed, ipatu':'\L l' A;
-""""-, " ~\"rr- ". f..' 1 -, ~ I.., ('"
;:.. L..J 'JJ., ) i,luL ;-:-'I':^ --f.-",-,v::>" \
~gnat witness 1f2
~ I C+C)t 1 c~l/0Q C. K SurJ
Printed Signature
~ ....:fJ.2 .,<' aAz fl...f.. ,8~t/ 'C(.,~l:~
si~~SHELL BOBBY DIXON rJ'
Printed Signature \- ..J
lIS- B w' tg L:Ir 66
Post om.e Add...... () r ^ i,/ i D'I,5'J,
D'-llrIX, {\i,
"11-18-~j:
..~ .-:'~:t ":~:".:: ~ ~_~
-;:'/1 A ')'i p:J COS
~:..r ,...I..~'"
:"i~
W.i.
Signature RECORe! IN;J
--:-',-.f<. ;-'Ii-MOC-
1 It ll' :J At I; - I
Printed SignniJioO
~- ,....' -- ~." ,,-'" ... -,,-
Signature
,~,
.~..:
Printed Signature
Signature
TOTtiJ :
A~~T N TENDEEED ~
ChANGt: ~
. . . .
"r. .
':.ttCd~:I L_:
$b::~, J.;~
Post om.e Add.....
CHEer;
Printed SI gnature
STATE OF NEW YORK
COUNTY OF {i5 R. {} ('-/ J(
. 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, personally appeared HERSHELL BOBBY DIXON, a / 5' I rJ (7 I E. man
to me known to be the person described in and
he Axecuted the same,
'/3 ,. ) day of December, . A,D, 19 91
. U~.J
o~,gnature ~~ ,
F. ucJa ~ \ l \N. LeI J
Jr.inte Notary Signarnre
My ComRu...i~n !>"Ph..., (" IfffC/C ~ I r '1;f
. LUCIA nSURCIO
COMMISSIONEn OF DEEDS
SEAt.jfy of New York 3-6077
Certifi?l~ Filed 10 Bronx eoun"
CommISsion E"Plres April '. I ~
'I
' ~
G
who executed the foregoing instrument and he acknowledged befo):
WITNESS my hand and official seal in the County and State last
KARLEEN F. DEBLAKERv CLERK
RECOF;D l,.JEf;IFIE:O. BYt_::Jl;f
"..
,"
M I 50l 1039) 1 l OMS No. 2502-0265
A. ' ~"';- 'U.S. DEPARTMENT OF HOUSING AND URB" DEVELOPMENT B. TYPE OF LOAN
~
1. 0 FHA 2, 0 FMHA 3, 0 CONV, UNINS,
4, OVA 5, 0 CONV, INS,
6, FILE 17, LOAN
SETTLEMENT STATEMENT NUMBER 91060110 NUMBER
8. MORTG. INS. CASE NO
C. NOTE: This form is furnished to aive you a statement of actual settlement costs, Amounts paid to and by the settlement agent are shown, Items marked
("p,o,c,") were paid outsi e the closing: they are shown here for information purposes and are not included in the totals.
D. NAME OF BORROWER: CITY OF CLEARWATER, FLORIDA
PO BOX 4748
ADDRESS: rr FT, ~L1h'7
E. NAME OF SELLER: DIXON, et. al
ADDRESS: SELLER TIN:
F. NAME OF LENDER:
ADDRESS: CASH TRANSAcrION
G, PROPERTY LOCATION: LarS 8,9 & 11, LESS S 50' FOR S'IREET, BLK 2, MJASE & HARRISON I S SUB OF
LOr 7 OF R.H. PADGETI'I S SUB
a/k/a 1127 & 1139 BROWNELL STREET, CLEARWATER, FL 34616
H, SETTLEMENT AGENT: STEWART TITLE COMPANY OF CLEARWATER, INC. SETTLEMENT AGENT TIN: 59-1433918
ADDRESS: 1290 COURT STREET I
CLEARWATER FL 34616
PLACE OF SETTLEMENT: STEWART TITLE COMPANY OF CLEARWATER, INC. I. SETTLEMENT DATE:
ADDRESS: 1290 COURT STREET DECEMBER 17, 1991
CLEARWATER FL 34616 351st DAY OF YF..AR/14 REMAIN
J. SUMMARY OF BORROWER'S TRANSACTION K, SUMMARY Of SELLER'S TRANSACTION
100. GROSS AMOUNT OUE FROM 80RROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract sales price 130,000.00 401. Conlract sales pfICe 130 000.00
102. Personal property 402 Personal property
103. Settlement charges to borrow (line /4110) 43.00 403
104. 404
105'IaMl3 SEIl.ERS CIfE]N; CIEIS 2.750.75; ; 405. CREDIT FKM HJYER rn CI03.IN:; crsrs 2 750.75
Adjustments for items paid by seller in advance: Adjustments for items paid for seller in advance:
106. City Itown taxes to 406. City Ilown taxes to
107. County taxes 10 407. County taxes 10
108. Assessments to 408 Assessments to
109 10 409 10
110 10 410 10
111. 411
112. 412
120 GROSS AMOUNT DUE FROM BORROWER: 132,793.75 420 GROSS AMOUNT DUE TO SELLER:: 132,750.75
200. AMOUNTS PAID BY DR IN BEHALf OF BORROWER: 500 REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deposit or earnesl money -0- 501. Excess depositlsee Instructions I
202. Principal amount 01 new loan(s) 502. Selllemenl charges 10 seller (line /400) 12,600.50
203 Existing loan(s) taken subjeclto 503. EXIsting loanls) taken subJect 10
204 . 504. Payol! of 'ust mortgage loan
205. 505. Payol! of second mortgage loan
206. 506. 1990 REAL ESTATE TAXES * 1 303.00
207. 507. PAYOFF JUDGEMENT IBERNARD DIXON 1. 345.08
208 508. PAYOFF JUDGEMENT/JOSEPH DIXON 14 132.90
209 509.
Adjustments for items unpaid by seller: Adjustments for items unpaid by seller:
210. City /Iown laxes to 510, City Itown taxes 10
211. County laxes to 51,. Counly taxes 1/1/91 to 12/17/91 * 1 321 32
212. Assessments to 512. Assessments to
213. to 513 to
214. 514. WELFARE LIENICHARLES DIXON R,.OO
215. 515. MR. GEORGE CROPPS/CLEANING * 35,00
216, 516. ATIDRNEY FEES/GRAY GIBBS * 421),10
217 517. JEAN CHANNEY/REIMBURSE TAXES * ?ooonn
218 518 MRS. ETMAN WRIGffi'/CLEANING * 15,00
219 519. REIMBURSE JOANNE DIXON/UPFRONT 150.00
__~l.~-!:_I: .!,CC;::'
220. TOTAL PAID BY/fOR BORROWER: -0- 520. TOTAL REDUCTION IN AMOUNT DUE SELLER:: 33,356.10
300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross amount due from borrower (line 120) 132,793.75 601. Gross amount due to seller (line 420) 11?750.75
302 Less amounts paid by /for borrower (line 220) -0- 602. Less total reductions in amount due seller (line 520) 33,35g.1Q
303. CASH IOHROM) taHij:BORROWER: 132,793.75 603, CASH [OnO) [rnDDM{SELLER: 99,394.65
SUBSTITUTE FORM 1099 SELLER STATEMENT.The information contained in Blocks E, G, H and I and on line 401 (or. if line 401 is aslerisked.lines 403 and 404) is important tax information and is being
turnished to the Internal Revenue Service, II you are required to file a return. a negligence penalty or other sanction will be imposed on you if this item is required to be reported and the IRS
determines that it has not been reported, .
SELLER INSTRUCTION.llthis real estate was your principal residence. file form 2119. Sale or Exchange ot Principal Residence, tor any gain. with your income tax return; for other transactions.
complete the applicable parts of form 4797. Form 6252 and/or Schedule 0 (Form 1040),
You are required by law to provide I. R. S with your correct taxpayer identification number,
It you do not provide I. R. S with your correct taxpayer identification number, you may be subject to civil or criminal penalties,
Under penalties of perjury, I certify that the number shown on this statement is my correct lax payer identification number.
. . I I
MIS LDI , PAGE 2 OF OMB No, 2502-0265
PAID FROM PAID FROM
L. SETTLEMENT CHARGES BORROWER'S SELLER'S
FUNDS FUNDS
700. TOTAL SALES/BROKER'S COMMISSION Blled 011 price I 130.000.00 @ "It= 10 000.00 AT SETTLEMENT AT SETTLEMENT
Division ot commission (line TOO) as follows:
701 $ * 7,249.26 to BLAN-EDWARDS REALTY, INC.
702. $ to
703. Commission paid at setllemenl * LESS 52750.74 TCMARDS SEILER CLOSING COSTS * 1() ()()() nn
704,
800 ITEMS PAYABLE IN CONNECTION WITH LOAN.
801. loan Origination fee %
802, loan Discounl %
803. Appraisal Fee 10
804. Credll Re~ort 10
805. lender's inspeclion lee
806. Morlgage Insurance application lee 10
807, Assumption Fee
808.
809.
810.
811.
900 ITEMS REQUIRED BY LENDER TO BE PAlO IN ADVANCE,
901. Inleresllrom to @$ Iday
902. Morlgage insurance premium lor mo,to
903. Hazard insurance premium tor yrs, to
904. yrs, to
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance mO,@$ per moo ~'
,
1002 Mortgage insurance mo,@$ per moo :
1003. City properly taxes mo,@$ per moo ,
1004. County property taxes mO,@$ per mo. 1;),~' ~ "
1005. Annual assessments (Maint.) mo,@$ per mo. "
1006. mO,@$ per mo.
1007. mo,@$ per.mo,
1008 mO,@$ per moo
1100. TITlE CHARGES:
1101. Setllement or closing tee 10
1102. Abstracl or tille search 10 STC * 300.00
1103. Tille examination to
1104. Tille insurance binder to
1105. Document preparation to
1106. Notary tees 10
1107. AlIorney's lees 10 to
. ' ,
(includes above ilems No.: - . ,
1108. Tille insurance (1101) to STEWART TITLE CCX\1PANY OF CLEARWATER. INC. * 1 210.00
(includes above ilems 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 S 43.00 Mortgage S Releases $ 6.00 JUDGEMENT /MYRI X 43.00 600
1202. Citylcounly taxlslamps: Deed S Morlgage $
1203. Stale taxlslamps: Deed S 780.00 Morlgage $ * 70"-' nn
1204. RECORD AFFIDAVITS/ awu.ES DELORES. JOSEPH. JEANETI'E
1205. 4 @ 6.00 EACG ?4,00
1206. RECORD SATISFACTION OF JUDGEMENT/JOSEPH 'K nTVr\l\l 10.l:i0
1300 ADDITIONAL SETTLEMENT CHARGES
1301. Survey 10 EVANS LAND SURVEYING POC
1302. Pest inspection 10 NO!' STED OR RFnI JIRFn
1303. MAlIA WAY PREPARATION/COURIER ?F;l:i00
1304. CITY OF CLEARWATER-LIEN SEARCH . * ").00
1305
1400. TOTAL SETTLEMENT CHARGES (entered on lines 103. Section J and 502. Section K) A':l ()() 1') h()"-' C:;,.-,
CERTlFICA TlON: I have carelully reviewed the HUD-l Satllemenl Slat,m,nt and to the be,' 01 my knowledge and bell",1l1a alrue and accurala Ilal'
that I have received a copy 01 HUD-l Selllement Slalem,n!. ./"
oy: crn V.I:" CLt;Al{WA'l'lli
Sellerl
ared is a true and4CCUrale account 01 Ihe funds which were received and have been or will be disbursed by Ihe undersigned as part or the selllemenl of Ihis Iransaction.
) IJEC~Vlli~K 17, 19~1
Selllemlnl A.llent i '-'- Data
SEllER'a AND/OR PURCHASER'S STATEMENT S,lIer'l and Purchaaer', Ilgnalura h"eon tcknowledg81 hlslthelr approval 01 lax proration, and lignifies their und"llandlng that prorallonl wIre basad on laxes lor the preceding year, or estimates
lor the current year, and In th, ev,nt ot any change lor the cur"nl year, all necenary adjullm,nll mutt be madl belwean Sail" and Purche,er; IIkewll' any delault In dellnqu'nllaxes will b, reimbursed to Tltie Company br, Ih, Sell",
Tille Company, In III capaclly II Escrow Agenl, II and has been aulhorlzed 10 d,pollt all lund, It "celvelln Ihl, Iransacllon In any t1nanclallnslltution, whelher atllllat,d or nol. Such f1nanclallnllltution may provide Tite Company compuler
accounting and audll services dlrectiy or through a separale ,nllly which, If aQlllated with Tllla Company, may charge the t1nanclallnalltullon reasonable and prop" compensation Iherelore and ,,'ain any proflls therelrom. Any escrow lses paid by any
party Involved in this lransacllon shall only be lor checkwrlllng and Inpullo Ih, compule", bul nollor alornald accounting and audit slfYlces, Till' Compeny Ihall nol be liable for any Int"esl or olh" charges on the earnest money and shall be und" no
duly 10 Invest or relnvesl funds held by it al any time, Sellers and Purchasers hereby tcknowledgeand constnllo the deposll oltheascrow money In t1nanclallnslilutionl wllh which Tille Company has or may have olh" banking relalionships and further
consenllo Ihe relention by Tille Company and lor its afliliates of any and all benellts (Includi"ll advanlageoullnt"est rates on loans} Tille Company andlor Its .Ilillatos may receive from such ',nanclall'IJlltullons by reason of their maintenance 01 said
escrow accounts.
1 he parties have read the above senlences, recognize Ihallhe recitalions herein are material. .gr.. to same, and recognize Title Com~s rel!fin{ on the sam~e, /TJ
PUlChasersj80rrower~ Sallerl ..td- g P _ ' ____ .A/"-~
oy: cl'l'Y 01" CL~I{WA'l't;[{ -__fIE.;RSI:!~_h___-'X_j:LXON____h .,
, T' BE FILLED IN PERSONALL i
BY SELLER OR'tWRROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
HERSHELL BOBBY DIXON
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
Approximate Amount
1/ All) IV e.
I-/-/)
.
1 No loans of any kind on said property except the following: (If none, so state.)
NAME AND ADDRESS 'OF CREDIT'OR '" Approximate Amount
~- %tlb~'
3. All 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 LAB 'OR, SERVICES 'OR MA TERIALS ') Approximate Amount
. ....- /}./ ,;' N eo"
/-1-.0
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, CREDIT'OR, SUPPLIER 'OF
LAB'OR '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 LAB'OR, 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 A ITORNEY'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 HAVE 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.
~ ~ ../J ~./A ..I.@ CJ) LAL'~
HERSHEI.L BOBBY DIXON ;
Rev, 1/88
,]
My Commission Expir; Iff (( ( -C II 19' f;3
blic in and ~rr ~ County, NEW YORK (1 t./ ()-'~1 (
NOTE: This rorm i. 10 be oiped by lellor in cale or ..Ie, If no ..Ie. il is 10 be .ipecl by lbe o.....-borrower, Ir lhe.. is any new conllruction. lhe conlr.ctor mUII.llo join in this rorm
or lian I separlJe: one.
- LUCIA 'RBUR~H\ EDS
UBSCRI~~O QI:.P~nlls""l 3 '/4, day of
'--Cllyonwn6rk1'MO ""
,~ ~t8 FRed m Bron" Coun., ~
Cocnmls8kIn EJpIrea Ap111, '"
DECEMBER
, 19 -9.l...- .
I
I.
NON-FOHE.LGN CE.H'l'H'lCl\TlON BY INIJl V lUUl\L TH1\NSF'EHOH
1. SecUun 1445 of: the Internal Hevenue Cooe provides that a trd\lSferee 1..[ a United
States real In"uperty interest must withhohl tax if the transferor is (J foreign ~rsol1.
2. In order to lnroJ.1" the transferee Lhat wiLhholding or Lox is nut required Upoll Lhe
dls(XJs.I. UOI' lW HERSHEIL BOBBY DIXON
of Lhe United SLates real property descr.1.bed os [ollows:
LOI'S 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, MOASE & HARRISON SUB
the undersigned transferor certifies and declares by means of lhis certification, the
following:
(a) I (We) am (ore) not lIon-resident alien(s) for IXJrposes of United Stales income
taxat.1,ol1 and,
(b) My Unil r..{] States taypapet" identifying IIUlllber(S) (Social Security Number) is/are:
N1\ME SOCI^L S~"'.CUHl'J"i NU\'1UEH
\
HERSHELL BOBBY DIXON II v' c:l W 5 - f5 6- 6 4-12-
ff
"
1/
(c) My hOllle mklreo9 18
(attached atkll,t1ollal lXlge if IlecessOJ:y)
(d) There ore 110 oLher: persolls who have on oWlle,:sh.l.p JIILerest ill Ule ol)()ve-descd~d
properLy oLll0.r Lhon lhose persollS set forth above ill subpc.u:ogroph (b).
J. 'JlIe llnders,i,gllcd hereby further cert.tfies and declares:
(a) I (We) understand that the IXJrchoser of the above described properLy in lends '
to r.ely on the [otegoing r.epresentations l.ll COllnect.i.on with the tln.tted Slates
fOl-eJgn Jllvesllllellt ill neal Property 'l'ax 1\ct. (94 Statute 2(;02 as amended).
(IJ) I. (wo) undcn-sLond LIds cerlJ.f.tcat.i.olllloy 1.Je tllSclosetl to the ll\lemal Hevellue
Serv.i.ce by tJ:ons[eree 0110 that ony false atatement contained ill Lhis ceru.r.i.cation
II1<.lY lJe! 1,1iIn.lslted hy Ll.llc~, Jlllpr.l.sonlllOllt ot' b>Lh.
Under ponolties or perjury I (we) declare I (we) have eXaJluneu carefully this certi-
fico tioll allu it is L rue, correc I:. and comple te .
J"... '3
DECEMBER I 3 1991 aty""
'v- ----fv:1I5'!1~>'V.'kha&l
Wltn~s .- ... ~ '
v .u/~Ib). I). t1A~,
Witness' , ,',.,
(1his document hlUst be retained wll:.il the end of the fifth taxable year following the ,I
taxable year In wh.lch the transfer takes place).
CONSUJJ1' YOUn 1\'lTOnNfrl l\NIJ/On 'l'1\X 1\IJVlSOIt - NO llEPHESE.'N'l'1\'1'lON on HECOMJI1ENDl\TION IS Nl\UE UY
S'.l'I!.Wl\H'J.' 'J.'.l'JU~ INStJHl\NCI~ ccr.1Pl\NY 1\NIJ/OH CONCEHNING '1'1 IE:
JJEGl\lJ SUrn,CIENCY l\NIJ/OH 'J'l\X CONSQUI!.'NCES Of' '11I1S OOCUr-11~N'.l'. YOU Ml\Y BE: ImQUlHI!D TO ~-'ILE:
1\ COpy m-' TillS rXX:lJMmfl' WJ TII '11"~ IN'l'EHNl\f~ H1W~lJl~ Sl~HV.lCI!:. 'n m:Sl~ l\1U!: QUI~S'l'.tONS FUH YOUH
^'1'l'OnNJ!:Y on 'l'^X ^IN ISOH.
S'l'1\'1'E OJ~ I.. NEW YORK
COUN'l"i m" v f/(dLJ fcllF
I IIEIU!:O'i Cf:.Il'l'U1"f thaI:. on L1tls day, before lIIe, on officer duly auLhorized in the state
aforesaId auu in the COUfll;y aforesaid to take oclmowleclgments, personally nppeared
HERSHELL BOBBY DIXON
to me Imown to be the perscJns described in and who execuled the foregoing .tnsLnuneut
and Lhey aclUlowletlyed before hie that they executed tlte Bailie. I"}
/ .....-
WITNESS my hand and official seal in the aforesaid lId.s
of DECEMBER , 19 9~
[)ate
I3R 011 )(
l.f
-
COUIlLy,
NEW YORK
4A~_h_ef D~'vt'T~'
HERSHELL BOBBY DIXON
I. ,r
, '
,','
10
"'"
~0h(
day
I
I
.")lInf'I;/v of t:Orllrlu"t
RONALD IRONI E, SOMERS
President
STEWAIl.'I~ 'I~I'I~LE
OF CLEARWATER
P,O, Box 2756
Clearwater, Florida 34617
(813) 441-2689
1290 Court Street
Clearwater, Florida 34616
D I S C LOS U R E
We, the Owners of that certain real property located at
LOI'S 8, 9 and 11, LESS S 50' FOR S'IREEI', 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.
(- 1J5LC, ~J2
?~~ \! ')~'L~'1J'---'>.. v .~
W1tness i.
V
~ ;J~..cM.plf ro~~l9-->V'
HERSHEIL BOBBY DIXON
V.'cT."f).;.ll~. 19 H o..if
Wi tness"
STATE OF =~ NEW YORK
COUNTY OF r/ g /! ON 'I.
(I
-
SWORN TO AND SUBSCRIBED BEFORE ME THIS
, 19~.
,.;' lUCtA 1JBURcla
.' COMM'SS'ONEn OF DEEO$
CertJ City 01 New York 3<<>n
Com Iica~ Fled In 8ton~ Courll',
~Phs Apn" H~~1
My Commission Expires:
DECEMBER
DAY OF
frp~-l I, I o;f.$
, ,
)
I--
(-'"
\) ( /-rl
I
,
I.
RONALD IRONI E. SOMERS
President
1290 Court Street
Clearwater, Florida 34616
S",,"(;I, .,/ rorlllnrt
S'rEW All.'r 'rrl~LE
OF CLEARWATER
P,O, Box 2756
Clearwater, Florida 34617
IB 13) 441-26B9
AUTHORIZATION AND ACKNOWLEIX;El'1ENT FORM
Reference:
FILE NO.
91060110
LEX;AL wrs 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, MOASE &
HARRISON SUB
SELLER
HERSHELL BOBBY DIXON
BUYER
CI'IY OF CLEARWATER, FLORIDA
We hereby approve and acknowledge receipt of a copy of the Statement, and actual
cost (DISCLOSURE/SETII.D1ENT 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 between the parties of
this transaction. Stewart Title Company of Clean.7ater, Inc., will not be held
responsible. It is further understood that Stewart Title Company of Clearwater,
Inc., carmot, at this time, assertain if there will be personal property tax on
subject property or an amount on which to base a proration. N1Y 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.
'IHAT ALL Ul'ILITY BILLS (WATER, SEI1ER, El..fX:'lRIC, MA:lN.l'I!M\Nrn FEES) HAVE BEEN PAID
OR WILL BE PAID UPON REX::EIPr OF FINAL BILLS.
.
/ J/f2AP.a/i ( ~1 ro~
HERSHELL BOBBY DIXON
vii /1 D
INITIALS
INITIALS
SELLER'S FORWARDING ADDRESS:
///5/1 Wlh9~ #-88
BUYER I S FORWARDING ADDRESS:
/lJflo/'J \(./ IV l( / oL/6 2
Ha1E PHONE#.(Z/2) 53Y-Oo/y
HQ'1E PHONE#
~RK PHONE# /'
WORK PHONE#
THIS IS TO FURTHER AUTHORIZE
CHANGES NECESSARY TO THE CLOSING STATEMENT.
TO APPROVE ANY
STEWART TITLE COMPANY {)F CLEARWATER, INe.
BY:
".
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 ,/" 2lo5-:-.51o-l.DtJ.I2Seller 2
Taxpayer ID Type:
2 ,(1 = business, 2 = individual)
SELLER 1 NAME:
Last:
DIXON
First & Middle:
HERSHELL BOBBY
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: I~ df. I- ..". i'2 L?
street :&./ / :./ 8 W / b i p:..-QJ?
City: 81!.tJr7'{ state: NY
SELLER 2:
street:
Zip Code: / b tf.6 2
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 STREET, CLEARWATER, FL 34616
Legal Description: LOTS 8, 9 and 11, LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON SUB I
Under penal ties of perjury, I, HERSHELL BOBBY 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.
Date V-/ 2./ /3/ c; I
, I
Seller - 1
S i g na t u r e :......... -f/..e.-;< 1O..A p i2R... 7),v,,- 8-x./
HERSHELL BOBBY DIXON
Signature:
Date:
Seller - 2
CLOSING AGENT INFORMATION (to be completed by closing agent)
Name:
STEWART TITLE COMPANY OF CLEARWATER, INC.
Mailing Address:
1290 COURT STREET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer 1D Number:
59-1433918