JEAN DIXON CHANEY
IIlJ,rr;;'~D: fen-;lo$8,.self-addressed stamped envelope)
..
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VJ _______ ,. 1;2.;.1, C';J~n'~ SlrClf-:U
This Instrument Prepared by: {;€:Jrw;.,!."r, FL ;H~!.;,
.1'0. lIn );75(,
ne:U'il':,'ei. t'L .\4/'.1'7
\':.'hJch lmrrl;m~ni W<JS I'repilfCd iw:id~nitli
10 writJm: cf [, TllI{: losman"" Pulk}.
Add,...:
- j
INST . 91-342288
910!1-1~,~,.~I._~~~--:-9'~~~- :I.: 4?F't1
F'INELLAS COUNTY FLA.
I OFF.REC.BK 7762 F'G 268
r;:~(; p{',:l'~:.~::~y,{:'nt WJ<),S pr~Z'ftr-:~d ~lY,~
fLQ,,) --.--
Property Appraisers Parcel Identification IFolio) Numberls):
l:l4-Jr,~.q-.lr~ ~('ax ~d,
Granteels) S.S, #[s):
SPACE ABOVE THIS LINE FOR PROCESSING DATA
:.
. ,"~
',U-
iiQ
REC
DS
INT
ITES
J-.ITF
PiC
REV
TOTA~
hy .__ _' ..,...
___.__ Lep'rt'f C!~r~{
SPACE ABOVE THIS LINE FOR RECORDING DATA
<nlttll Barrantv IIttb Made the / ,1 rl7 day of December, A.D, 19 91
JEAN DIXON CHANEY, a/ ~1t~fiIJZ b woman
hereinafter called the grantor, to
CITY OF CLEARWATER, FLORIDA
whose post office address is P.O. Box 4748, Clean~ater, Fl. 34617-4748
by
hereinafter called the grantee:
(Wherever uoed herein the t.erms 'grantor' and .grantee' include aU the parties to thi. instrument and the
heiro, legal repre.entative. and ...Igno of Individual., and the .ucce..oro and ..sign. of corporations)
.ftntlulttlJ: 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 confirms unto the grantee all that certain land situate in Pinellas
County, State of Florida , mz:
Lots 8, 9 and 11 less south 50ft. 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, 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 County,
Florida of which Pinellas County was formerly a part.
Parcel no. 15/29/15/58338/002/0080 Grantors soc. sec. II 1> 7.'] .2.:(- 0 'z 0 (JEAN)
Property is not the principal residence of the Grantor, she in fact resides at:
/ 7003 SPfllt:~vl! si IPi-hIt9/J,:. LPillli, Pc';"A. i /q 1/1
aJngttJrtt. With all the tenements, hereditaments and appurtenances thereto belonging or in any'Wise
appertaining.
aJn )lant anb tn lInlb. the same in fee simple for'-':lIer.
Anil 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 ~es accr:uil!'~ subse~ent to ,gecember 91, 19 91, and all easements
In .itntss ."tttnf. t~ saif1~~~~toc,. '1ta~~~g'?ea t:i~la~e.d these presents the day and year first above
written.
Signed, sealed and delivered in the presence of:
('?:1~j~L ,~
t1;!.,t&~~ .s To I< ~ ~
/l--ULtA~)X ::Ja.k~
Signature f
I tfL CA) . '7IfKRESKJ
Prin Signatnre
~ /1 ," /1'4-'
, . ' ,/V vto1V L/'" ~ ~
I tUN
I JEAN DIXON CHANEY
Print.ed Signature
IJ(}J3 c.... D'-~\J,(, ~~.\..
P~t<>lnce Ad~Q~_\ \a.c\\f~;~ (' A
Signature
~
Signature
Printed Signature
Print.ed Signature
Signature
Poot Omce Addreu
Print.ed Signaturl
STATE OF PENNSYLVANIA
COUNTY OF'P+tJ t...~~L.<pffil)
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 JEAN DIXON CHANEY, a /(1{fiRf</~ woman
~~ .: to me known to be the person described in and
who ex~ut~d 'toe f9regoing Jnlltrument and she acknowledged before me that She_executed the same.
WI'lNESS my hw ~"lficlaI "'" In th, County ~d Stote IUl_!,~ lhl'/,> 3'~ doy ~f DeC~' A,D, 1991
/Nota~~~1 ~ '- ~ L~
L V'-= /~ />;, ~) PU<",Za x.J i
Print.ed No ry Signatul'e ~
NOTARIAL SEAL My Commi ion Exph'e.:/ ~~ 'd.-...;;t ) 7;;-c
LUCIA M. CIPOLLONI. Notary Public
City of Philadelphia. Phila. County
My Commissi~.~._~xpires Dec. 22. 1992
SEAL -(
'.;' .;, I:" I::'I:~ I".J I::' T, 1",:'1;' 1 .;, ,.;' !::. !::' (~I 1::'1::' V
1.1"........... ., !..,...,.....II'.....;...~....,."
RECORD VERIFIED BY: ~
/3q-j/3
(..
M/S-LO! I I PAGE 2 OF OMS No. 2502-0265
" . . PAID FROM PAID FROM
, L. SEnLEMENT CHARGES
BORROWER'S SELLER'S
FUNDS FUNDS
700 TOTAL SALES/BROKER'S COMMISSION Baaed 1NI price S 130.000.00 @ D/r 10 000.00 AT SETTLEMENT AT SETTLEMENT
Division of commission (line 7(0) as follows:
701$ * 7,249.26 10 BLAN-EDWARDS REALTY. INC.
702 $ to
703, Commission paid al selllemenl * LESS S2750.74 'l'CMARDS SELLER CLOSING COSTS * 10 f"lf"lf"l f"lf"l
704.
800 ITEMS PAYABLE IN CONNECTION WITH lOAN.
801. Loan Originalion fee %
802, Loan Discount %
803, Appraisal Fee 10
804, Credit Reporl 10
805, Lender's inspection fee
806. Mortgage Insurance application fee to
807, Assumption Fee
808,
809,
810,
811.
900 ITEMS REQUIRED BY lENDER TO BE PAID IN ADVANCE.
901,Inleresl from to @s /day
902, Mortgage insurance premium tor mo. 10
903, Hazard insurance premium for yrs.lo
904. yrs. to
905.
1000, RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance mO,@$ per mo.
1002 Mortgage insurance mO.@$ per mo,
1003, City property taxes mO.@$ per mo. ,
1004, County property taxes mo,@S per mo. .' '.
1005. Annual assessmenls (Maint.) mo,@S per mo,
1006 mo,@S per mo.
1007. mo@S permo.
1008, mo.@S per mo.
1100 TITlE CHARGES:
1101, Settlemenl or closing fee to
1102, Abstracl or lille search to STC * 300.00
1103, Tille examination to
1104, Tille insurance binder to
1105. Document preparation 10
1106, Notary lees to
1107, AUorney's fees to to
(includes above items No,:
1108, Tille insurance (1101) 10 STEWART TITLE CO'1PANY OF CLEARWATER. INC. * 1 210.00
(inCludes 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 Morlgage S Releases $ 6.00 JT.JIX;EMENT /MYRI "K 43.00 600
1202, City/county tax/stamps: Deed $ Morlgage S
1203, Stale lax/slamps: Deed $ 780.00 Mortgage $ * '7Qf"l f"lf"l
1204, RECORD AFFIDAVITS/CHARLES DELORES. JOSEPH _ JEANEITE
1205, 4 @ 6.00 EACG ?4.00
1206. RECORD SATISFAcrION OF JUDGEMENT/JOSEPH FREDERIrK DTXOl\l 1n,t;n
1300 ADDITIONAL SETTlEMENT CHARGES
1301, Survey to EVANS LAND SURVEYING POC
1302. Pest inspection to Nor RFnUESTED OR RFnUIRED
1303, MAlLAWAY PREPARATION/COURIER ?ht:; nn
1304, CI'IY OF CLEARWATER-LIEN SEARCH * t;on
1305
1400 TOTAL SETTlEMENT CHARGES (entered on Imes 103, SectIOn J and 502, Sect/on K) L1< nn l? hnn c:;n
CERTIFICATION: I have carefully reviewed the HUD.l Settlement Statement and 10 the beslo' my knowledge and bellef,ll/s a true and
that I have received a copy of HUj}.1 Settlement Slatement.
Sell
e pr~ared is a true and accurate account 01 the funds which were receIved and have been or will be disbursed by the undersigned as part of the seUtemenl of this transaction,
U!;t':l:'lVJljr;t{ 17, 19~1
Settlement Allent ,../ ..' Date
SellER'S AND/OR PURCHASU'S STATEMENT Seller's and Purchaser's signature hereon acknowledges hisllhelr approval 01 lax prorations and signifies their understanding Ihat prorations were based on lues for the preceding year. oreslimates
far Ihe current year, and in the evenl of any change lor the current year, all necessary adjustments mUSI be made between Seller and Purchaser; likewise any delault In delinquenltaxes will be reimbursed to Title Company by, the Seller.
Title Company, in its capacity as Escrow Agent, is and has been authorized to deposit all 'unds It receives In this Iransactlon In any flnanclallnstllutlon, whether affiliated or not Such financial Institution may provide Til e Company compuler
accounting and audit services directly or through a separate entlly whic:h, If afflllaled with TIlle Company, may charg.lhe llnanclallnstlfutlon reuooable end proper compensation Ihere'ore and relaln any prollts therelrom. Any escrow'.es paid by any
party involved in this transaction shall only bs'or checkwrlting and Inpul to the computers, but nol'or a'oresald accounting and audit Hrvlc:es, Title Company shall not be liable lor any Interest or other charges on the earnest money and shall be under no
duty to invest or reinvest funds held by It at any time. Sellers and Purchasers hereby acknowledge and conHnt 10 lhedeposlt oflhe escrow 1l100Dy In f1nanciallnslltutlons with whic:h mle Company has or may have other banking relationships and further
consent 10 t, he relention by Titls Company and/or Its affltiates of any and all benellts (Including advanlageous Interesl rates on loans) Title Company and/ lis a" ffillates mayzecelve m such flnanc/al Instltutlo s by reason olthelr maintenance of said
escrow accounts. . " ~ c~ f' ~ _) _ /)
The parties have read the above sentences. recognize thaI the recitations herein are malerlal. agree to same, and recognize Title Compan is re 0 th~ ~ V {. "'V
purchasers~arrowert Sellers ... 1
_..__.__.Y:-=-__ l'l'Y 01:" CU.Al{WA'U:I:{ DI:xON CHANEY .1
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.';1111('1;1.1' of COIII",,:t
RONALD (RONI E. SOMERS
President
STEW AR'r 'I'I'l'I..E
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
LOl'S 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, MJASE & 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.
~v!m!lJ~'~
Witness
l~~,~
JEAN DIXON 'CHANEY
. ~-Jit~<-' ~;'k~~'
Witness - _/
STATE OF
COUNTY OF
'3
....
PENNSYLVANIA
@t-+ )L:f)'X.LP /1/ //
~
)3
DAY OF
1
SWORN TO AND SUBSCRIBED BEFORE ME THIS-
DECEI'ffiER
, 19 91.
My Commission
;~~~~~
~J\ Notary Public
Expires: W~ ~ ~. J 99 c...
')
., . NOT ;;AL SEAL pSb~ I
'j). M CIPOLLONI. N?tary I'}Y?
, LUC~I"; of .plli\adelplli~, PhD"ae'cC~t1992
'J .' Evplres . '
My commIsSIon ~__
~
,f
Td BE FILLED IN PERSONALL ~
BY SELLER OR BORROWER IN HIS OWN HANDWRITING
INDEMNITY AND AFFIDAVIT AS TO DEBTS, LIENS, AND POSSESSION
USE SEPARATE FORM FOR EACH PARTY
JEAN DIXON CHANEY
- -, - ~. ... t
Seller or Owner-Borrower
LOI'S 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
\ App~oximate Amo~
v~, J!
.
2. No loans of any kind on said property except the following: (If none, so state,)
NAME AND ADDRESS OF CREDITOR ,') V" A~!7~~ Am~.
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 \ ;pp.r-7~~~ _~moun'-},--"
tI
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 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.
I realize that the purchaser and / or lender in this transaction are relying on the representation contained herein in purchasing
sa lending m e thereon and ~u~ not purchase same or lend money thereon unless said representations were made,
'1 v' t.nU UtA .
(JEAN DIXON CHANEY
..- """ -V- .
SWORN TO AND SUBSCRIBED BEFORE ME THIS r:3 day of
DECEMBER
91
,19_,
'1
\,.
..,.. My Commissio ~~f~~ NOTARIAL SEAL
Notary Public in and f~rY" "'d?A1f)County, PENNSLYVANIA cr Cittm Phila~)Phia.Fr.~:'tou~~C
. ". . . Mv Commission r:~oires Dec. 22. 1992
NOTE: Th.. form .. 10 lie ..",ee1 by lelle, In "Ie or ule, If no ule, 111110 lie liped by lhe o.....'.borrower. If there iI Iny new conllrudion, the conlract . " . rm
Rev. 1/88 0' Ii... I "'....... one.
"
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I
NON-FOHE.LGN CE.H'l'H'lCAT.LON BY INIJIVJlJUAL 'l'1V\NSfEHOH
1. Section 1445 of: the I11terl1a1 He venue COOe prov.l.des lhat [1 lrd\lSferee 1)[ a Uniled
States reol properly interest must w.l.thhold tox if the transferor is ij foreign tJerson.
2. In order La 111[on" Lhe Lransferee Lhat wlLhholtHlIg of Lax Js 1I0t required upon Lhe
d.lspos.l.Uon hy JEAN DIXON CHANEY
of lhe UnlLed SlaLes real properly descdbed as [ollows:
LOTS 8, 9 and 11, LESS S 50 I FOR STREET, BLK 2, MOASE & HARRISON SUB
the undersigneU transferor certifies and declares by means of this certification,' the
following:
(a) I (We) am (are) not lloll-resident alienee) for p.lrposes of United SLales income
laxat.lon and,
(b) My Ullil cd Slates laypapet" identifying IIlllllber(s) (Social Security Number) is/are:
NJV.1I!: SOCI^L S~X:UIU'l'Y NUNDl!.lt
- -
JEAN DIXON CHANEY
Iv 07,3 -.;< 8'. Oi:J.()
II
II
"
(c) My home mldnms 1s
(ul:tochcd otldlUonol IXlUe .l.r lIecessaJ:y)
(d) There ore flO oLher persolls who have on oWlle,:shJp JnLerest ill Lhe aLXJve-descd.lJed
property oLhr:Jr Lhan lhose versons set forth obove ill subparogroph (b).
J. '.l.lIe 1II1dersJgm_,<1 hereby [ut"ther cerUfJ.es olld declares:
(a) I (We) understand that the p.lrchaser of the above described property inlends .
Lo r.e.ly on the [otegoinU r.epresenLatJons i.ll connection wllh Lhe lIn.l.t:ed SLoLes
l"oreJgn Investl11ellt ill Heal ProperLy Tax Act. (94 Statute 2602 as U1llellc1ed).
(b) I. (we) Ul1detALnlld lids certJ.HcaUolI IIny be dlsclosed Lo lIm ItlLemal Hevellue
Servlce by transferee anu that any false statement contained in LIds cerUUcallon
Illi.1Y 1)0 r>lIIl.l.sh(!11 hy f.l.llu, .i.l11pt.l.sOll1110l1t ot" both.
Under p0l1u1l1es of perjury I (we) declare I (we)
fication and it is Lrue, correct and complete.
~... -ctz '2
Date DECEMBER ):?, 1991 at v
have exa1l11ned carefully L1lis certi-
~ ) LI1..oELtf'HJ1tcoUIlLy,
y"""') AI -
'J~ vio-u.J
, DIXON CHANEY
PENNSYLVANIA
f)V M(L/J J2;-4~
Wi tness 0" ~
v' 2Ud ~ ~h~'
Witness . >J' .'"
(111is document hust be retained wltil the end of the fifth taxable year following the'!
taxable year In whlch the transfer takes place).
CONSUJJlf YOUIt Nl'lUHNI!:Y 1\NIJ/on 'I'l\X 1\IJVlSOn '- NO HEPHESEN'I'1\TION on HECQ\1NENU1\'l'lON IS N/\lJE UY
ST~W/\H'l' 'J.'l'j'L1~ INSlJltANCg c{~1Pl\N'i 1\NIJ/OH CONCEHNJNG 'fIlE
U~GA'J SUFF.l.CIENCY ^NIJ/OH 'tAX CONSQUI~'NCES OLi' '11I1S OOCUI'11!:N'l'. YOU 1'11\Y BE ImQUlmn TO F'ILE:
^ COpy OF TillS IXX:tJMliNl' Wl'l'lI 'l'11I~ IN'l'EHNArJ IUWI~:NtJl~ SI~HV.lCI!:. 'J1w:sr: /\HI~ QUF.S'1'lONS FOH yaUH
^TmHNI~ on 'l'/\X /\l)v lSOH.
S'1'^,l'~ OJ~ (,. PENNSYLVANIA
COUNTY m' ~ nt) c ~ D ~ LB!-) ~
I IIEm~O'i C~-;n'l'Ill"{ that 011 lItls day, before me, an officer duly authorized in the State
aforesaid and in the COIJnty aforesaid to take acknowledgments, personally nppeared
JEAN, DIXON CHANEY
to me Imown to be the persons described in and who executed the foregoing .instrul1lent
and Lhey acknowledged before hIe that they executed the same. f,_ XJ,--
WITNESS "IY hand and official seal in the County ond SLate la~t aforesaid thls)3 ' clay
of DECEMBER , 19 91
(!j~~.
t.: II"
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~h~
NOl'/\RY JJIC "/
MY Cal'lISSION EXPIRES:
~~L
NOTARIAL SEAL .
( LUCIA M. CIPOLLONt Notary Public
~11 City of Philadelphia. Phila. cou~~92
.' Mv Commi55io~_~~p!."es Dec. 22,
~
.:::.:::',:
~ " '
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LNFORMATION 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 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 ".,..07:& -~ S - 0/). 0 Seller 2
Taxpayer ID Type:
2
(1 = business, 2 = individual)
SELLER 1 NAME:
Last:
CHANEY
First & Middle:
JEAN DIXON
SELLER 2 NAME:
Last:
First & Middle:
MAILING ADDRESS (as of January 31 of next year)
SELLER 1: 7 :i <",
street: V""" 0 ().;J '-.J PI( /I G 0 ~
City: All/II be l PII, A
SlifE e-r
state: !i,t/A/I1, Zip Code: /CfI/t:J
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 pr1ce among the sellers)
Description .of Property:
Street Address: 1127 & 1139 BROONELL S'IREET, CLEARWATER, FL 34616
Legal Description:
LOTS 8,9 and 11, LESS S 50' FOR STREET, BLK 2, MOASE & HARRISON
SUB
Under penalties of perjury, I,
JEAN DIXON CHANEY
(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
l099-S that will be sent to me and to the Internal Revenue S ~vice.~ ~ '
Date:./ l,fl.' 13- 9 J Seller - 1 Signature:_ . ) ~.~
JEAN DIXON CHANEY
Date:
Seller - 2 Signature:
CLOSING AGENT INFORMATION (to be completed by closing agent)
STEWART TITLE COMPANY OF CLEARWATER, INC.
Name:
Mailing Address:
1290 COURT Sl'REET
City:
CLEARWATER
State:
FL
Zip Code:
34616
Taxpayer ID Number:
59-1433918
~
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."a",:I;/, of Co,.t,n.,-t
RONALD (RON) E, SOMERS
President
1290 Cou rt Street
Clearwater, Florida 34616
S'I'EWAI~'l" ~rrl~LE
OF CLEARWATER
P.O. Box 2756
Clearwater, Florida 34617
(B 131 441.2689
AUTHORIZATION AND ACKNOWLEI:X;EMENT FORM
Reference:
FILE NO.
91060110
LEGAL LOl'S 8, 9 and 11, LESS S 50 I FOR S'IREET, BLK 2, MOASE &
SELLER
JEAN DIXON GIANEY
CITY OF CLEARWATER, FLORIDA
HARRISON SUB
BUYER
We hereby approve and acknowledge receipt of a copy of the Statement and actual
cost (DISCLOSURE/SETTI.n1ENT 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 Clearwater, 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 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.
'!HAT AIL lJI'ILITY BILLS (WATER, S~, ELEX:'lRIC, MAlN'I'mANCE FEES) HAVE BEEN PAID
OR WILL BE PAID UPON ROCEIPl' OF FINAL BILLS.
~
./?~~ /~ ~
JEAN DIXON CHANEY
INITIALS
INITIALS
SELLER'S FORWARDING ADDRESS:
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Ha1EPHONE# vtc? /6" ) d 'I- d '-d c.J tj I
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BUYER I S FORWARDING ADDRESS:
Ha1E PHONE#
WORK PHONE#
'!HIS IS TO FURTHER AUTHORIZE
CHANGES NECESSARY TO '!HE CLOSING STATEMENT.
TO APPROVE. ANY
STEWARr TITLE' ca1PANY OF CLEARWA'l'ER, INC.
BY: