HELEN D MORGAN (5)A. Settlement Statement
Buyer /Seller
Settlement Statement
B. Type of Loan
oo 1. FHA
�) 4. V.A.
O 2. FmHA
0 5. Conv. Ins.
0 3. Conv. Unins.
6. File Number
04- 2013 -4369
ID:
7. Loan Number
8. Mortg. Ins. Case Num.
C. NOTE:This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items
marked "(p.o.c.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals.
D. NAME OF BUYER:
Address of Buyer:
E. NAME OF SELLER:
Address of Seller:
F. NAME OF LENDER:
Address of Lender:
G. PROPERTY LOCATION:
H. SETTLEMENT AGENT:
Place of Settlement:
I. SETTLEMENT DATE:
The City of Clearwater, Florida, a municipal corporation of the State of Florida
112 South Osceola Avenue, Clearwater, Florida 33756
Helen D. Morgan, an unmarried woman
1140 Brownell Street, Clearwater, Florida 33756
1140 Brownell Street, Clearwater, Florida 33756
Matthew B. Sullivan, Esq.
4756 Central Avenue, St. Petersburg, Florida 33711
7/30/14
DISBURSEMENT DATE: 7/30/14
TIN:
TIN: 26-4497091
Phone: 727-592-1957
101. Contract sales price
92,000.00
401. Contract sales price
92,000.00
102. Personal property
-
402. Personal property
103. Settlement charges to buyer (Line 1400)
118.50
403.
104.
-
404.
105.
106. City /town taxes
-
-
405.
406. City/town taxes
107. County taxes
-
407. County taxes
108. Assessments
-
408. Assessments
109.
-
409.
110.
-
410.
111.
-
411.
112.
-
412.
20. G oss a o ' t • = f • ' =
201. Deposit or eamest money
92,118.50
-
420. Gross amount due to seller:
501. Excess deposit (see instructions)
92,000.00
202. Principal amount of new loan(s)
-
502. Settlement charges to seller (line 1400)
1,697.00
203. Existing loan(s) taken subject to
-
503. Existing loan(s) taken subject to
204. Principal amount of second mortgage
-
504. Payoff of first mortgage loan
205.
-
505. Payoff of second mortgage loan
206.
-
506. Deposits held by seller
207. Principal amt of mortgage held by seller
-
507. Principal amt of mortgage held by seller
208.
-
508.
209. Fronted deposit
210. City /town taxes
500.00
-
509. Fronted deposit
510. City/town taxes
500.00
211. County taxes from 01/01/14 to 07/30/14
95.00
511. County taxes from 01/01/14 to 07/30/14
95.00
212. Assessments
-
512. Assessments
213.
-
513.
214.
514.
215.
-
515.
216.
-
516.
217.
-
517.
218.
-
518.
219.
-
519.
220. Total paid by/for buyer:
301. Gross amount due from buyer
(line 120)
595.00
92,118.50
520. Total reductions in amount due seller:
601. Gross amount due to seller
(line 420)
2,292.00
92,000.00
302. Less amount paid by /for the buyer
(line 220)
(595.00)
602. Less total reductions in amount due seller
(line 520)
(2,292.00)
303. Cash ( H From [ 1 To ) Buyer:
91,523.50
603. Cash ( r i To From ) Seller:
89,708.00
Substitute Form 1099 Seller Statement: The information contained in blocks E, G, H, and I and on line 401 is important tax information and is being
furnished to the IRS. If 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 Instructions: If this real estate was your principal residence, file Form 2119, Sale or Exchange of Principal Residence, for any gain, with your tax
return; for other transactions, complete the applicable parts of Form 4797, Form 6262 and /or Schedule D (Form 1040).
Buyer's Initial(s):
e /7/
Seller's Initial(s):
DoubleTlme®
•
Buyer/Seller Settlement Statement
Page 2
700. Total Sales/Brokers Com. based on price
$94,000.00 ®
%=
701.
% to
702.
% to
703. Commission paid at settlement
704.
to
801. Loan origination fee
% to
Paid from
Buyer's
Funds at
Settlement
Paid from
Seller's
Funds at
Settlement
802. Loan discount
% to
803. Appraisal fee
to
804. Credit report
to
805. Lender's inspection fee
to
806. Mortgage insurance application fee
to
807. Assumption Fee
to
808.
to
809.
to
810.
to
811.
901. Interest from
to
to
/da
902. Mortgage insurance premium for
months to
903. Hazard insurance premium for
ears to
904. Flood insurance premium for
ears to
905.
ears to
1001. Hazard insurance
months
•er month
1002. Mortgage insurance
months CO
•er month
1003. City property taxes
months CO
•er month
1004. County property taxes
months
•er month
1005. Annual assessments
months ®
•er month
1006. Flood insurance
months
•er month
1007.
months CP
•er month
1008.
months
•er month
1009. Aggregate accounting adjustment
1101. Settlement or closing fee
to Matthew B. Sullivan, Esq.
1102. Abstract or title search
to Matthew B. Sullivan, Esq.
1103. Title examination
to
1104. Title insurance binder
to
1105. Document preparation
to
1106. Notary fees
to
1107. Attorneys Fees
to
(includes above item numbers:
1108. Title Insurance
to Old Republic Nat. Title/Matthew B. Sullivan
(includes above item numbers:
1109. Lender's covera•e (Premium):
1110. Owner's coverag e (Premium): $92,000.00 ($529.00)
1111. Endorse:
1112.
to
1113.
to
1201. Recording fees
Deed
$18.50 Mort•a•e s
Releases
1202. City/county tax/stamps
Deed
Mort•a•e s
1203. State tax/stamps
Deed
$644.00 Mort•a•e s
1204.
to
1205.
to
1301. Survey
to
1302. Pest Inspection
to
1303. Home Inspection
to Brad Garey Home Inspections, Inc.
1304.
to
100.00
125.00
529.00
18.50
644.00
399.00
1305.
to
1306.
to
1307.
to
1308.
to
1309.
Enter on lines 103 Section J and 502 Section K
118.50
1,697.00
I have carefully reviewed the Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on
my account or by me in this trans.. ction. I further certify that I have received a copy of the Settlement Statement.
T Ci f Cle• a ,'/I
By: //V/
Charles Lane, Administrator
The Settlement Statement
statement.
Matthew B.
By:
ave prepared is
veCSC
true an
Buyer
Buyer
Helen D. Morgan
Seller
Seller
accurate account of this transaction. I}lave caused, or will cause, the funds to be disbursed in accordance with this
7 '3 dfri
As Authorized Representative- Date
WA ' ING: It is a crime to knowingly make f• se statements to the United States on this or any other similar form. Penalties upon conviction can include a fine
a imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010.
DoubleTime®
PREPARED BY AND RETURN TO:
Matthew B. Sullivan, Esq.
4756 Central Avenue
St. Petersburg, FL 33711
$92,000.00
WARRANTY DEED
THIS WARRANTY DEED is made this1' , day of July 2014 by, HELEN D. MORGAN,
an unmarried woman, whose address is 1140 Brownell Street, Clearwater, FL 33756 (the "Grantor"),
in favor of THE CITY OF CLEARWATER, FLORIDA , a municipal corporation of the State of
Florida, whose address is 112 South Osceola Avenue, Clearwater, FL 33756 (the "Grantee "):
(Whenever used herein the terms "Grantor" and "Grantee" include all the parties to this
instrument and the heirs, legal representatives and assigns of individuals, and the
successors and assigns of corporations.)
WITNESSETH: That the Grantors, 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, and Grantee's heirs, successors and
assigns forever, all that certain land situated in Pinellas County, Florida, and described as follows:
Lot 11, Block 1, Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision,
according to the map or plat thereof as recorded in Plat Book 2, Page 85, Public Records of
Hillsborough County, Florida, of which Pinellas County was formerly a part.
Parcel I.D. 15- 29 -15- 58338- 001 -0110
Subject to easements, restrictions, reservations and limitations of record, if any.
TOGETHER with all the tenements, hereditaments and appurtenances thereto belonging or in any
way appertaining. TO HAVE AND TO HOLD THE SAME IN FEE SIMPLE FOREVER.
AND the Grantor hereby covenants with said Grantee that the Grantor is lawfully seized of
the Property in fee simple; that the Grantor has good right and lawful authority to sell and convey the
Property; that the Grantor hereby fully warrants the title to the Property, and will defend the same
against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances
except taxes and assessments accruing subsequent to December 31, 2013.
[Signature appears on the following page.]
1
IN WITNESS WHEREOF, the said Grantor has caused this deed to be executed by its
duly authorized officer on the day and year first above written.
Witnesses:
Print Name: a(Lu,(c.-C Coat-1�
STATE OF FLORIDA
COUNTY OF PINELLAS
Helen D. Morgan
By: "M`' -" c
Helen D. Morgan
The foregoing instrument was acknowledged before me on July 2014, by HELEN D.
MORGAN, she is personally known to me, or has produced FL. D . C, vizt.C... as
identification.
SEAL
0:*;,, GRACE L REGISTER
MY COMMISSION # EE127608
'';°'chess°:` ` EXPIRES September 05, 2015
(407)1398 -0153 FloridallotaryService.c0m
2
�lQ
2e
( ign. ture) N TARY P LI
Print Name: ace L. r 3t.,S e
My Commission Expires: G -S i
A. Settlement Statement
U.S Department of Housing
and Urban Development
OMB Approval No. 2502 -0265
B. Type of Loan
1.0 FHA 2.0 RHS 3.0 Cony. Unins.
4.0 VA 5.0 Cony. Ins.
6. File Number
FN146427
7. Loan Number
8. Mortgage Insurance Case Number
C. Note: This form is fumished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items
marked "(p.o.c.)" were paid outside the closing; they are shown here for information purposes and are not induded in the totals.
D. Name and Address of Borrower
HELEN DAVIS
1823 FLORA LANE
CLEARWATER, FLORIDA 33755
E. Name and Address of Seller
Fannie Mae A/K/A Federal National Mortgage
Association
REO if A140CXC
Loan #1695804465
14221 Dallas Parkway Suite 1000
Dallas, TX 75254
F. Name and Address of Lender
G. Property Location
1823 FLORA LANE
CLEARWATER, FLORIDA 33755
H. Settlement Agent
TYLER A. GOLD, P.A.
1250 S Pine Island Rd, 4450, Plantation, FL 33324
Place of Settlement
1250 S PINE ISLAND ROAD
SUITE 450 (954) 565 -5577
PLANTATION, FL 33324
I. Settlement Date
07/30/14
07/30/14
J. SUMMARY OF BORROWER'S TRANSACTION:
K. SUMMARY OF SELLERS TRANSACTION:
100. GROSS AMOUNT DUE FROM BORROWER
400. GROSS AMOUNT DUE TO SELLER
101. Contract sales price
85,000.00
401. Contract sales price
85,000.00
102. Personal property
402. Personal property
103. Settlement charges to borrower (line 1400)
1,677.20
403.
104.
404.
105.
405.
Adjustments for items paid by seller in advance
Adjustments for items paid by seller in advance
106. City /town taxes to
406. City/town taxes to
107. County taxes to
407. County taxes to
108. Assessments to
408. Assessments to
109.
409.
110.
410.
111.
411.
112.
412.
120. GROSS AMOUNT DUE FROM BORROWER
86,677.20
420. GROSS AMOUNT DUE TO SELLER
85,000.00
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER
500. REDUCTIONS IN AMOUNT TO SELLER
201. Deposit or eamest money
500.00
501. Excess Deposit (see instructions)
202. Principal amount of new loan(s)
502. Settlement charges to seller (line 1400)
5,198.75
203. Existing loan(s) taken subject to
503. Existing loans taken subject to
204.
504. Payoff of first mortgage loan
205.
505. Payoff of second mortgage loan
206.
506.
207.
57.
208.
508.
209.
509.
Adjustments for items unpaid by seller
Adjustments for items unpaid by seller
210. City/town taxes to
510. City/town taxes to
211. County taxes 01/01 to 07/30
1,064.79
511. County taxes 01/01 to 07/30
1,064.79
212. Assessments to
512. Assessments to
213.
513.
214.
514.
215.
515.
216.
516.
217.
517.
218.
518.
219.
519.
220. TOTAL PAID BY / FOR BORROWER
1,564.79
520. TOTAL REDUCTION AMOUNT DUE SELLER
6,263.54
300. CASH AT SETTLEMENT FROM OR TO BORROWER
600. CASH AT SETTLEMENT TO OR FROM SELLER
301. Gross amount due from borrower (line 120)
86,677.20
601. Gross amount due to seller (line 420)
85,000.00
302. Less amounts paid by/for borrower (line 220)
1,564.79
602. Less reduction amount due to seller (line 520)
6,263.54
303. CASH FROM BORROWER
85,112.41
603. CASH TO SELLER
78,736.46
EMSELVES
IN THE EVEN? RE- PRORATION OF THE TAXES IS NECESSARY WHEN THE TAX BILLS FOR 2013 ARE PREPARED. THE PARTIES AGREE TO HANDLE SAID RE- PROBATIONS BETWEEN TH .
4
HELEN DAV
Fannie Mae AM/A Federal National Mortgage Association
By, Hole E Adams. Signatory on Van Ness Law Firm PLCAIF
07/30/14
FINAL - 07 -28 -2014 at 10:55 AM
form HUD -1 (3/86) ref Handbook 4305.2
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
L. SETTLEMENT CHARGES: File Number. FN146427
700. TOTAL SALESIBROKERS COMMISSION based on price $ 85,000.00 @ 5.50
4,675.00
SETTLEMENT STATEMENT
Division of commission (line 700) as follows:
701. $ 2,125.00 to SUNRAYE REALTY
702. $ 2,550.00 to COLDWELL BANKER
703. Commission paid at Settlement FANNIE PD BY SUNRAYE REALTY
704. TECHNOLOGY FEE TO
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Origination Fee
802. Loan Discount
803. Appraisal Fee to
804. Credit Report to
805. Lender's Inspection Fee to
806. Mtg. Ins. Application Fee to
807. Assumption Fee to
808.
809.
810.
811.
812.
813.
814.
815.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE /day
901. Interest from to ($
902. Mortgage Insurance Premium to
903. Hazard Insurance Premium yrs. to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER FOR
1001. Hazard Insurance
1002. Mortgage Insurance
1003. City property taxes
1004. County property taxes
1005. Annual Assessments
1006.
1007.
1008. .
mo. @$ 1 mo.
mo. as / mo.
mo. @$ I mo.
mo. as
I mo.
mo. @$ 1 mo.
mo. @$ / mo.
mo. as Imo.
1100. TITLE CHARGES
1101. Settlement or closing fee to TYLER A. GOLD, P.A.
1102. Abstractor title search to TYLER A. GOLD, PA.
1103. Title examination to
1104. Title insurance binder to
1105. Document preparation to
1106. Notary fees to
1107. Attorney's fees to
(includes above item No:
1108. Title insurance to TYLER A. GOLD, PA./FIRST AMERICAN TITLE I
(includes above item No:
1109. Lenders coverage
1110. Owner's coverage 85,000.00 - 488.75
1111. SELLER REP FEE VAN NESS LAW FIRM
1112. Municipal Lien/Tax Search LIGHTNING LIEN LETTERS INC
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording fees Deed $ 3820 ; Mortgage $
1202. City/county /stamps Deed $ ' Mortgage S
1203. State tax/Stamps Deed $ 595.00 ; Mortgage $
1204. Intangible Tax Deed $ ; Mortgage $
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest inspection to
1303. WIRE FEE TYLER A. GOLD, PA.
1304. COURIER FEE TYLER A. GOLD, PA.
1305. DIGITAL STORAGE FEE ROI SYSTEMS, INC.
1306. TRANSACTION /PROCESSING FEE COLDWELL BANKER
1307. .
1308.
1400. (enter on lines 103 and 502, Sections JFanf K) AIWA Federal Nalianat Mortgage 4umalron
1 nave carefully reviewed the HUD-1 Settlement Statement and to the best d my knowledge and ballet. It a a we anti aoc eeete smtemere d el receipts and disbursements made an my account or by me in this
transaction. I further certify that I have received a copy of the HUD -1 Settlement Statement
; Releases $
P.O.C.
PAID FROM
BORROWERS
FUNDS AT
SETTLEMENT
300.00
150.00
PAGE 2
PAID FROM
SELLERS
FUNDS AT
SETTLEMENT
194.00
38.20
595.00
20.00
35.00
345.00
1,677.20
4,675.00
- 125.00
488.75
150.00
10.00
5,198.75
Hoar E Adams, Signatory on Van Ness Law Firm PLCAIF
The HUD-1 Settlement Statement vauich I have prepared is a we and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement
Date
MER A GOLD. P.A. conviction can include a Me a imprisonment For details sea: Title 18 U.S. Cade
WARNING: It is a crime to knowingly make false statements to Oro United States on this w any other similar form. Penalties upon convi
Section 1001 and Section 1010.
FINAL - 07 -28 -2014 at 10:55 AM
form HUD -1 (3/86) ref Handbook 4305.2
Closing Affidavit
(Seller)
Before me, the undersigned authority, personally appeared Helen D. Morgan, an unmarried woman ( "Affiant "), who
being by me first duly sworn, on oath, depose(s) and say(s) that:
1. Helen D. Morgan, an unmarried woman ( "Seller "), is the owner of and is selling the following described property to
The City of Clearwater, Florida, a municipal corporation of the State of Florida ( "Buyer "), to wit:
Lot 11, Block 1, Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision, according
to the map or plat thereof as recorded in Plat Book 2, Page 85, Public Records of Hillsborough
County, Florida, of which Pinellas County was formerly a part
2. The above described property is free and clear of all liens, taxes, encumbrances and claims of every kind, nature and
description of record whatsoever, except for mortgage or mortgages, if any, described in the Deed and except for real
estate and personal property taxes for the year 2014, which are not yet due and payable.
3. There have been no improvements, alterations, or repairs since acquisition by the Seller to the above described property
for which the costs thereof remain unpaid, that there are no claims for labor or material furnished for repairing or
improving the same, which remain unpaid since the acquisition by Seller, and that there are no mechanic's,
materialmen's, or laborer's liens since acquisition by Seller against the above described property.
4. There have been no documents recorded in the Public Records of Pinellas County, Florida subsequent to , which
affect title to the Property and Seller has not entered into any contracts for the sale, disposition or leasing of the
Property since said date except as may have been disclosed to Matthew B. Sullivan, Esq. in writing, and Seller has no
knowledge of any matter affecting title to the Property.
5. The personal property contained in the building on said property, or on the said premises, and which, if any, is being
sold free and clear of all liens, encumbrances, claims and demands whatsoever. The Seller knows of no violations of
Municipal or County Ordinances pertaining to the above described property. No judgment or decree has been entered in
any court in this State or the United States against said Seller which remains unsatisfied. There are no persons other
than Seller in possession of the above described property.
6. Seller agrees that in the event the current real estate or personal property taxes vary in amount from the figures used in
making the prorations used in closing the transfer and conveyance of the above described property to said buyers, then a
new proration and a correct and proper adjustment will be made upon demand.
7. There are no matters pending against the Seller that could give rise to a lien that would attach to the property between
the effective date of commitment and the recording of the interest to be insured. Seller has not and will not execute any
instruments that would adversely affect the interest to be insured.
8. Seller's title to, and possession and enjoyment of, the property have been open, notorious, peaceable and undisturbed,
and have never been disputed nor questioned.
9. There are no disputes concerning the boundary lines of the property, and the operation of any buildings on said
property has been in compliance with the applicable building codes, ordinances and statutes.
10. Affiant has received no notice of any public hearing regarding assessment for improvements or changes in applicable
zoning laws concerning said property within the past ninety (90) days.
11. There are no actions or proceedings now pending in any State or Federal Court to which the Seller is a party, including
but not limited to, proceedings in bankruptcy, receivership or insolvency, nor are there any judgments, bankruptcies,
liens or executions of any nature which constitute or could constitute a charge or lien upon said property.
12. There are no unrecorded easements, claims of easement or rights -of -way affecting all or any portion of the property.
File Number 04- 2013 -4369 DoubleTime®
13. Seller understands that Section 1445 of the Internal Revenue Code provides that a Buyer of a United States real
property interest must withhold tax if the Seller is a foreign person. To inform the Buyer that withholding of tax is not
required upon purchase of the above described property, Seller certifies the following:
a. Seller is not a nonresident alien individual, foreign corporation, foreign partnership, foreign trust or foreign estate
for purposes of United States federal income taxation.
b. Seller's U.S. Taxpayer Identification Number is .
c. Seller's address is: 1140 Brownell Street, Clearwater, FL 33756.
d. No other persons or entities have an ownership interest in the above described property.
Seller understands the Buyer of the described property intends to rely on the foregoing representations in connection
with the United States Foreign Investment in Real Property Tax Act. (FIRPTA). Seller understands this certification
may be disclosed to the Internal Revenue Service by the Buyer and that any false statements contained in this
certification may be punished by fine, imprisonment or both. Seller has the authority to sign this affidavit as either
individual Seller or on behalf of an entity Seller. Under penalties of perjury, Seller states that this declaration was
carefully read and is true and correct.
14. This affidavit is given for the purpose of clearing any possible question or objection to the title to the above referenced
property and, for the purpose of inducing Matthew B. Sullivan, Esq. and Old Republic National Title Insurance
Company to issue title insurance on the subject property, with the knowledge that said title companies are relying upon
the statements set forth herein. Seller hereby holds Matthew B. Sullivan, Esq. and Old Republic National Title
Insurance Company harmless and fully indemnifies same (including but not limited to attomeys' fees, whether suit be
brought or not, and at trial and all appellate levels, and court costs and other litigation expenses) with respect to the
matters set forth herein. "Affiant ", "Seller" and "Buyer" include singular or plural as context so requires or admits.
Seller further states that he /she is familiar with the nature of an oath and with the penalties as provided by the laws of
the United States and the State of Florida for falsely swearing to statements made in an instrument of this nature. Seller
further certifies that he/she has read, or heard read, the full facts of this Affidavit and understands its context.
Under penalties of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true.
Helen D. Morgan L •
State of Florida
County of Pinellas
The foregoing instrument was sworn to and subscribed before me this 30th day of July, 2014 by Helen D. Morgan, who
[1 is personally known or [X] has produced a driver's license as ider}tifjcation.
[Notary Seal]
;iy !" sE;: GRACE L REGISTER
••�i-�
•'; MY COMMISSION # EE127608
• EXPIRES September 05, 2015
(407) 398 -0153 FloridallotaryService.com
Closing Affidavit (Seller) - Page 2
File Number: 04- 2013 -4369
Not6ry Public
Printed Name: CCiC L„ L- Pecy&-kr
g My Commission Expires: /J
DoubleTime®
CERTIFICATION FOR NO INFORMATION REPORTING
ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE
This form may be completed by the seller of a principal residence. This information is necessary to determine whether the
sale or exchange should be reported to the seller, and to the Internal Revenue Service on Form 1099 -S, Proceeds From Real
Estate Transactions. If the seller properly completes Parts I and III, and makes a "true" response to assurances (1) through
(6) in Part II (or a "not applicable" response to assurance (6)), no information reporting to the seller or to the Service will be
required for that seller. The term "seller" includes each owner of the residence that is sold or exchanged. Thus, if a
residence has more than one owner, a real estate reporting person must either obtain a certification from each owner
(whether married or not) or file an information return and furnish a payee statement for any owner that does not make the
certification.
Part L Seller Information
1. Name: Helen D. Morgan
2. Address or legal description (including city, state, and ZIP code) of residence being sold or exchanged:
1140 Brownell Street, Clearwater, FL 33756
3. Taxpayer Identification Number (TIN):
Part II. Seller Assurances
9'7g
Check "true' or "false" for assurances (1) through (5), and "true ", "false ", or "not applicable" for assurance (6).
True False
True False N/A
(1) I owned and used the residence as my principal residence for periods aggregating 2 years
or more during the 5 -year period ending on the date of the sale or exchange of the
residence.
(2) I have not sold or exchanged another principal residence during the 2 -year period ending
on the date of the sale or exchange of the residence.
(3) I (or my spouse or former spouse, if I was married at any time during the period beginning
after May 6, 1997, and ending today) have not used any portion of the residence for
business or rental purposes after May 6, 1997.
(4) At least one of the following three statements applies:
The sale or exchange is of the entire residence for $250,000 or less.
OR
I am married, the sale or exchange is of the entire residence for $500,000 or less, and the
gain on the sale or exchange of the entire residence is $250,000 or less.
OR
I am married, the sale or exchange is of the entire residence for $500,000 or less, and (a) I
intend to file a joint return for the year of the sale or exchange, (b) my spouse also used the
residence as his or her principal residence for periods aggregating 2 years or more during
the 5 -year period ending on the date of the sale or exchange of the residence, and (c) my
spouse also has not sold or exchanged another principal residence during the 2 -year period
ending on the date of the sale or exchange of the principal residence.
(5) During the 5 -year period ending on the date of the sale or exchange of the residence, I did
not acquire the residence in an exchange to which section 1031 of the Internal Revenue
Code applied.
(6) If my basis in the residence is determined by reference to the basis in the hands of a
4 person who acquired the residence in an exchange to which section 1031 of the Internal
Revenue Code applied, the exchange to which section 1031 applied occurred more than 5
years prior to the date I sold or exchanged the residence.
Part III. Seller Certification
Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange.
CY Signature orSeller Date
DoubleTimeo
Closing Affidavit
(Buyer)
Before me, the undersigned authority, personally appeared the undersigned ( "Affiant "), who being by me first duly
sworn, on oath, depose(s) and say(s) that:
1. The City of Clearwater, Florida, a municipal corporation of the State of Florida ( "Buyer "), is purchasing the
following described property from Helen D. Morgan, an unmarried woman ( "Seller "), to wit:
Lot 11, Block 1, Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision, according
to the map or plat thereof as recorded in Plat Book 2, Page 85, Public Records of Hillsborough
County, Florida, of which Pinellas County was formerly a part
2. Buyer's marital status as reflected in this affidavit and the other closing documents is true and correct. The Buyer is of
legal age and has never been adjudged incompetent. There are no matters pending against the Buyer that could give
rise to a lien that would attach to the property prior to the recording of the interests to be insured, and Buyer has not
and will not execute any instrument (nor permit any action to be taken) that would adversely affect the title or interests
to be insured. There are no judgments or liens against Buyer and no bankruptcy proceedings are currently pending with
respect to Buyer.
3. To the best of Buyer's knowledge, information, and belief: (a) within the past 90 days there have been no
improvements, alterations, or repairs to the above described property for which the costs thereof remain unpaid, and
that within the past 90 days there have been no claims for labor or material furnished for repairing or improving the
same, which remain unpaid; (b) there are no actual or potential mechanic's, materialmen's, or laborer's liens against the
property; (c) there are no tenancies, leases or other occupancies (oral or written) affecting the property; (d) no other
person or entity has any contract to purchase, option to purchase, right of first refusal, or other potential claim of right
to purchase the property.
4. Buyer knows of no violations of municipal ordinances pertaining to the property, or any action or proceeding relating to
the property which is pending in any court, nor does the Buyer know of any judgment, tax lien, or matter of any nature
whatsoever which could create a lien or charge upon the property. Buyer has no knowledge of any matters that could or
does create a cloud on the title to the subject property.
5. There are no matters pending against the Buyer that could give rise to a lien that would attach to the property between
the effective date of commitment and the recording of the interest to be insured. Borrower has not and will not execute
any instruments that would adversely affect the interest to be insured.
6. There are no actions or proceedings now pending in any State or Federal Court to which the Buyer is a party, including
but not limited to, proceedings in bankruptcy, receivership or insolvency, nor are there any judgments, bankruptcies,
liens or executions of any nature which constitute or could constitute a charge or lien upon said property.
7. This affidavit is given for the purpose of clearing any possible question or objection to the title to the above referenced
property and, for the purpose of inducing Matthew B. Sullivan, Esq. and Old Republic National Title Insurance
Company to issue title insurance on the subject property, with the knowledge that said title companies are relying upon
the statements set forth herein.
8. Buyer hereby holds Matthew B. Sullivan, Esq. and Old Republic National Title Insurance Company harmless and
fully indemnifies same (including but not limited to attorneys' fees, whether suit be brought or not, and at trial and all
appellate levels, and court costs and other litigation expenses) with respect to the matters set forth herein. "Affiant ",
"Seller" and "Buyer" include singular or plural as context so requires or admits. Buyer is familiar with the nature of an
oath and with the penalties as provided by the laws of the United States and the State of Florida for falsely swearing to
statements made in an instrument of this nature. Buyer has read, or heard read, the full facts of this Affidavit and
understands its context.
File Number: 04- 2013 -4369 DoubleTime®
Under penalties of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true.
The City of Clearwater, Florida, a municipal corporation of
the Stat orida
By:
Charles Lane, Administrator
(Corporate Seal)
State of Florida
County of Pinellas
The foregoing instrument was sworn to and subscribed before me this 30th day of July, 2014 by Charles Lane of The City
of Clearwater, Florida, a municipal corporation of the State of Florida, on behalf of the corporation. He/she [J is
personally known to me or [X] has produced a driver's license as identification.
[Notary Seal]
;:*"-%l GRACE L REGISTER
T. MY COMMISSION # EE127608
2015
EXPIRES September 05,
(407) 398 -0153 FloridallotaryService.com
Closing Affidavit (Buyer) - Page 2
File Number: 04- 2013 -4369
Notary Public
Printed Name:
ex-a ce. is-le
My Commission Expires: v! 5 ^/ Ea
DoubleTimee
Non - Foreign Certification By Individual Transferor
(Seller's FIRPTA Affidavit)
Transferor: Helen D. Morgan, an unmarried woman
Transferee: The City of Clearwater, Florida, a municipal corporation of the State of Florida
Property 1140 Brownell Street, Clearwater, FL 33756
Closing Date: July 30, 2014
Before me, the undersigned authority, personally appeared the person(s) named in paragraph 2(b) below who, after being
duly sworn, stated as follows:
1.
This certificate is to inform the transferee that withholding Federal Income Tax is not required, upon the sale of the
following described real property
Lot 11, Block 1, Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision, according
to the map or plat thereof as recorded in Plat Book 2, Page 85, Public Records of Hillsborough
County, Florida, of which Pinellas County was formerly a part
2. The undersigned Transferor certifies and declares as follows:
a. I am not a foreign person for purposes of United States income taxation, and am not subject to the tax withholding
requirements of Section 1445 of the Internal Revenue Code of 1954, as amended.
b. My United States taxpa �.iden ification or Social Security number is:
Helen D. Morgan ( )
c. My home address is:
1140 Brownell Street, Clearwater, FL 33756
d. There are no other persons who have an ownership interest in the above described property other than those
persons listed in paragraph 2(b) above.
3. The undersigned hereby further certifies and declares:
a. I understand the purchaser of the described property intends to rely on the foregoing representations in connection
with the United States Foreign Investment in Real Property Tax Act. (FIRPTA).
b.
I understand this certification may be disclosed to the Internal Revenue Service by the transferee and that any false
statements contained in this certification may be punished by fine, imprisonment or both.
Under penalties of perjury, I state that this declaration was carefully read and is true and correct.
. v\ ` 9 — 2 c(-
Helen D. Morgan
DoubleTime®
State of Florida
County of Pinellas
The foregoing instrument was sworn to and subscribed before me this 30th day of July, 2014 by Helen D. Morgan, who
[_] is personally known or [X] has produced a driver's license as identificjation.
[Notary Seal]
`° ;_ GRACE L REGISTER
". MY COMMISSION # EE127608
:ft ;: f �ti EXPIRES September 05, 2015
(407 ) 398 -0153 FforidallotaryService.com
Non- Foreign Certification by Individual Transferor - Page 2
Oc
Not a fy Public
Printed Name: &race_
My Commission Expires: 1
DoubleTime®
OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY
COMMITMENT
Schedule A
Fund File Number: 04- 2013- 004369
Effective Date:
December 10, 2013 @ 11:00
PM
1. Policy or Policies to be issued:
Agent's File Reference: Premium:
MORGAN /CITY OF CLEARWATER
Proposed Amount of Insurance:
OWNER'S: ALTA Owner's Policy (06/17/06). (With Florida Modifications) $94,000.00
Proposed Insured: The City of Clearwater, Florida
MORTGAGEE:
MORTGAGEE:
2. The estate or interest in the Land described or referred to in this Commitment is FEE SIMPLE.
3. Title to the FEE SIMPLE estate or interest in the Land is at the Effective Date vested in:
Helen D. Morgan a/k/a Helen D. Davis
4. The Land referred to in this Commitment is described as follows:
Lot 11, Block 1, Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision, according to the map or plat
thereof as recorded in Plat Book 2, Page 85, Public Records of Hillsborough County, Florida, of which Pinellas County
was formerly a part
Issuing Agent:
Matthew B. Sullivan PA
4756 Central Avenue
St. Petersburg, FL 33711
Form CF6- SCH. -A (rev. 12/10) (With Florida Modifications)
OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY
400 Second Avenue South, Minneapolis, MN 55401, (612)
371 -1111
Page 1 of 3
OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY
COMMITMENT
Schedule B -I
Fund File Number:
04- 2013 - 004369
I. The following are the requirements to be complied with:
e
(1/7
Agent's File Reference:
MORGAN /CITY OF
CLEARWATER
Payment of the full consideration to, or for the account of, the grantors or mortgagors.
Instruments creating the estate or interest to be insured which must be executed, delivered and filed for record:
Warranty Deed from Helen D. Morgan a/k/a Helen D. Davis, joined by spouse, if married, or non - homestead
language, to the proposed purchaser(s).
Proof of payment of taxes for the year 2013 must be furnished, and any tax certificates issued with respect thereto must
be canceled by the clerk of the court.
Satisfaction of the mortgage from Helen D. Davis, single to Walter Home Improvement, Inc., a Florida corporation
dated March 23, 1989, and recorded in O.R. Book 6988, Page 2106, Public Records of Pinellas County, Florida.
Record satisfaction, release or credible proof of non - identity containing the legal description of the subject property
and relating to the following Certified Judgment(s) against the name of Helen Morgan and Helen Davis recorded in the
following Official Records: 13124/778 and 15787/979, Public Records of Pinellas County, Florida .
Record satisfaction of those certain Liens recorded in O.R. Book 18146, Page 477, O.R. Book 18174, Page 1000 and
O.R. Book 18204, Page 2175, Public Records of Pinellas County, Florida. Alternatively, record release of the liens of
such Liens as to the subject property.
A search commencing with the effective date of this commitment must be performed at or shortly prior to the closing
of this transaction. If this search reveals a title defect or other objectionable matters, an endorsement will be issued
requiring that this defect or objection be cleared on or before closing.
Form CF6- SCH. -B -I (rev. 12/10)
Page 2 of 3
OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY
COMMITMENT
Schedule B -II
Fund File Number:
04- 2013- 004369
Agent's File Reference:
MORGAN /CITY OF
CLEARWATER
II. Schedule B of the Policy or Policies to be issued will contain exceptions to the following matters unless the same are
disposed of to the satisfaction of the Company:
Defects, liens, encumbrances, adverse claims or other matters, if any, created, first appearing in the Public Records or
attaching subsequent to the Effective Date hereof but prior to the date the Proposed Insured acquires for value of
record the estate or interest or Mortgage thereon covered by this Commitment.
.a. General or special taxes and assessments required to be paid in the year(s) 2013 and subsequent years.
Rights or claims of parties in possession not recorded in by the Public Records.
/ Any encroachment, encumbrance, violation. variation, or adverse circumstance that would be disclosed by an
inspection or an accurate and complete land survey of the Land and inspection of the Land.
y 'Easements, or claims of easements, not recorded in the Public Records.
/e Any lien, or right to a lien, for services, labor, or material furnished, imposed by law and not recorded in the Public
Records.
3. Any Owner Policy issued pursuant hereto will contain under Schedule B the following exception: Any adverse
ownership claim by the State of Florida by right of sovereignty to any portion of the Lands insured hereunder,
including submerged, filled and artificially exposed lands, and lands accreted to such lands.
4. All matters contained on the Plat of Moase and Harrison's Subdivision of Lot 7 of R.H. Padgetts Subdivision, as
recorded in Plat Book 2, Page 85, Public Records of Hillsborough County, Florida, of which Pinellas County was
formerly a part.
5. Reservations in favor of the State of Florida, as set forth in the deed from the Trustees of the Internal Improvement
Fund of the State of Florida, recorded in O.R. Book 945, Page 349, Public Records of Pinellas County, Florida.
Rights of the lessees under unrecorded leases.
4
Form CF6- SCH. -B -II (rev. 12/10)
Page 3 of 3