SETTLEMENT STATEMENT AND OWNER AGREEMENT
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10 {::/1 / / S- / 72000
U.S. Department of Housing
and Urlian Development
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A.' SETTLEMENT STATEMENT
OMB No. 2502-0265
B. Tvpe of Loan
1. - FHA 2. - RHS 3. .!.. Cony. Unins. 6. File Number 7. Loan Number 8. Mortgage Insurance Case Number
4. - VA 5. - Cony. Ins.
06.2490
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 information purposes and are not included in the totals.
D. Name and Address of Borrower E. Name and Address of Seller F. Name and Address of Lender
Grant A.J. Boshoff City of Clearwater Signature Bank
Venussa Boshoff
100 S. Myrtle Avenue. #220 100 Second Avenue N.
509 N. Prescott Avenue Clearwater. Fl 33756 St. Petersburg. Fl 33701
Clearwater. Fl 33755
G. Property Location H. Settlement Agent
FREEDOM TITLE AGENCY. INC.
501 Pennsylvania Avenue
Clearwater. Fl 33755 Place of Settlement I. Settlement
1465 S. Fort Harrison Avenue Date
Suite 102 04/28/06
Clearwater. Fl 33756
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
100. Gross Amount Due From Borrower 400. Gross Amount Due To Seller
101. Contract sales price 37.550.00 401. Contract sales price 37.550.00
102. Personal property 402. Personal property
103. Settlement charges to borrower (line 1400) 5.719.53 403.
104. Escrow Holdback for Construction 113.300.00 404.
105. 405.
Adiustments for items paid by seller in advance Adjustments for items paid bv seller in advance
106. City/town taxes to 406. City/town taxes to
107. Countv 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 156.569.53 420. GROSS AMOUNT DUE TO SELLER 37.550.00
200. Amounts Paid By or In Behalf of Borrower 500. Reductions In Amount Due To Seller
201. Deposit or earnest money 501. Excess Deposit (see instructions)
202. Principal amount of new loan(s) 135.765.00- 502. Settlement charges to seller (line 1400) 181. 00
203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
204. 504. Payoff of first mortgage loan
205. 505. Payoff of second mortgage loan
206. 506. Record Quitclaim Deed 10.00
207. 507.
208. 508.
209. 509.
Adiustments for items unpaid bv seller Adiustments for items unpaid bv seller
210. City/town taxes to 510. City/town taxes to
211. County taxes to 511. County taxes to
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 135.765.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 191. 00
300. Cash At Settlement From or To Borrower 600. Cash At Settlement To or From Seller
301. Gross amount due from borrower (line 120) 156.569.53 601. Gross amount due to seller (line 420) 37.550.00
302. less amounts paid by/for borrower (line 220) 135.765.00 602. less reduction amount due seller (line 520) 191.00
303. CASH FROM BORROWER 20.804.53 603. CASH TO SELLER 37.359.00
04-26-2006 at 12:23 PM
RESPA, HB 4305.2 -- REV. HUD-l (3/86)
U.S..,PE~AFWMENT OF HOUSING AND URBAN DEVELOPMENT
SETTLEMENT STATEMENT
PAGE 2
L.~~TTLEMENT CHARGES: FILE #: 06-2490 PAID FROM PAID FROM
700. TOTAL SALES/BROKER'S COMMISSION based on price $ @ = BORROWER'S SELLER'S
Division of commission (line 700) as follows: FUNDS AT FUNDS AT
701. $ to SETTLEMENT SETTLEMENT
702. $ to
703. Commission paid at Settlement
704.
800. ITEMS PAYABLE IN CONNECTION WITH LOAN P.O.C.
801. Loan Origination Fee %
802. Loan Discount %
803. Appraisal Fee to Sunbelt Real Estate Appraisers 325.00
804. Credit Report to Credit Services. Inc. 25.00
805. Lender's Inspection Fee to
806. Mtg. Ins. Application Fee to
807. Assumption Fee to
808. Lenders Inspection Fee Sunbelt Real Estate Appraisers 450.00
809. Flood Cert LSI Flood Services 14.00
810. Tax Related Service Fee LSI Tax Services 55.00
811. Underwriting Fee Signature Bank 250.00
812. Pre-Collected End Loan Fees Signature Bank 750.00
813.
814.
815.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest from to @$ /day Days
902. Mortgage Insurance Premium for to
903. Hazard Insurance Premium for yrs to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER FOR
1001. Hazard Insurance mO.@$ /mo.
1002. Mortgage Insurance mO.@$ /mo.
1003. City property taxes mo.@$ /mo.
1004. County property taxes mo.@$ /mo.
1005. Annual Assessments mO.@$ /mo.
1006. mo.@$ /mo.
1007. mO.@$ /mo.
1008.
1100. TITLE CHARGES
1101. Settlement or closing fee to Freedom Title Agency, Inc. 125 . 00 125.00
1102. Abstract or title search to 01 d Republ ic 65.00
1103. Title examination to Freedom Title Agency, Inc. 65.00
1104. Title insurance binder to
1105. Document preparation to Tradewinds Doc Prep Co Inc. 135.00
1106. Notary fees to
1107. Attorney's fees to
(includes above items No: )
1108. Title insurance to Freedom Title Agency, Inc. 1,253.00
(includes above items No: (MP-R25) )
1109. Lender's coverage $ 135.765.00 -.-- 395.00
1110. Owner's coverage $ 37.550.00 ..-- 858.00
1111. Endorsements FF9. 8.1 Freedom Title Agency. Inc. 143 .50
1112. Assessment Check Fee City of Clearwater 5.00
1113. Titl e Updates Freedom Title Agency. Inc. 300.00
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording fees Deed $ 10.00; Mortgage $ 214.00; Releases $ 0.00 224.00
1202. City/county/stamps Deed $ Mortgage $
1203. State tax/stamps Deed $ 263.20; Mortgage $ 475.30; 738.50
1204. Intangible Tax Deed $ Mortgage $ 271.53; 271.53
1205. Re 1 eases/Handl i ng
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to KnON it NON. Inc. 525.00
1302. Pest inspection to
1303. Courier/handling fees Freedom Title Agency. Inc. 36.00
1304. Re;mb notary fee QC Deed Frank Phalen 20.00
1305.
1306.
1307.
1308.
1400. TOTAL SETTLEMENT CHARGES (enter on lines 103 and 502, Sections J and K) 5.719.53 181.00
IN THE EVENT A RE-PRORATION OF THE TAXES IS NECESSARY WHEN THE TAX BillS FOR 2000 ARE PREPARED, THE PARTIES AGREE TO HANDLE SAID RE-PRORATION
BETWEEN THEMSELVES. I have carefully reviewed the HUD-l Settlement Statement and to the best of my knowledge and beliel, It Is a true and accurate statement
01 all receipts an rsements made on my account or by me in this transaction. I lurther certify that I have received a copy 01 the HUD-l Settlement Statement.
I . ate
crl to knowingly make false statements to the United States on this or any other similar lorm. Penalties upon conviction can include a line and
deta s see: Title 18 U.S. Code Section 1001 and Section 1010.
04-26-2006 at 12:23 PM
RESPA, HB 4305.2 -- REV. HUD-l (3/86)
,
PRIVACY POLICY NOTICE
OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY
. AND
FREEDOM TITLE AGENCY, INC.
. 635 CLEVELAND ST.
CLEARWATER, FL ~3755
PURPOSE OF THIS NOTICE
Title V of the Gramm-Leach-Bliley' Act (GLBA) generally prohibits any financial institutions,
. directly or through its affiliates, from sharing nonpublic personal information about you with a,non-
affiliated third party unless the institution provides you with a notice of its privacy policies and
practices, such as the type of information t~at it collects about you and the categories ofp.ersons or
entities to whom it may be disclosed. In compliance with the GLBA, we are providing you with this
document, which notifies you of the privacy policies and practices of Old Republic National Title
Insurance Company and Freedom Title Agency, Inc..
We may c<?lIect nonpublicpersonal information about you from the f?llowing sources:
. Infonnat.ien we receive from you sUch as on applications or other fonns.
. Infonnation about your transactions we secure from our files, or from [our affiliates or] others.
. Infonnation we receive from a consbmer repOrting agency. '. .
. Information that we receive.from others involved in your transaction, such as real estate agent or lender.
Unless it is specifically stated otherwise in' an amended Privacy Policy Notice, no additional
nonpublic personal inforn:tation will be ~ol1ected about you.
, ' '
We may disclose any of the above information that we collect about oUf customers or fonner
customers to our affiliateS or to non-affiliated third parties as permitted by law.
, '
We may also disclose this information about our customers or former customers to the following
types of non-affiliated companies that perfonn.scrvices on our behalf or with whom we have joint
marketing agreements:
.
Financial service providers such as companies engagcid in banking. consumer finance, securities and insUrance.
Non-financial companies such as envelope stuffers and other. fulfillment service providers,
.
WE DO NOT DISCLOSE ANY NONPUBLIC PERSONAL JNFORMA110N ABOUT YOU WITH
ANYONE FOR ANY PURPOS~ THAT IS NOT SPECIFICALLY PERMIITED BY LAW.
We,restrict.accesst? no.npublic persona~ informa~ion about you to th~se employees who need to
know ~at mformatlon m 9rder to proVIde products or services to you. We maintain physical,
electrom~ and p~dural safeg~ards that comply wi~ federal regulations to guard your nonpublic
personal mformation. ' .
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111111111
FLORIDA DEPARTMENT OF REVENUE Approval Code LT8610141299
RETURN FOR TRANSFERS OF INTEREST IN REAL PROPERTY PHOTOCOPIES OF DR219
(PLEASE READ INSTRUCTIONS ON THE BACK OF THIS FORM BEFORE COMPLETING) THIS FORM NOT R.07/98
ACCEPTABLE LTFL
Parcel Identification Number
1. (If Parcel 10 not available
please call County Property
Appraiser's Office)
2. Mark (x) all
that apply
Multi-parcel
transaction?
Transaction Is a spilt
or cutout trom
another parcel?
Property was Improved
with bulldlng(s) at time
of sale/transfer?
3. Grantor (Seller) Ci ty of Clearwater
100 S. Myrtle Avenue, #220, Clearwater, FL 33756
4. Grantee (Buyer) Grant A.J. Boshoff and Venussa Boshoff
509 N. Prescott Avenue, Clearwater, FL 33755
5. Date of Sale/Transfer
04 / 17
/
2006
SalelTransfer Price
$ 37,550.00
Property
Located In
62
County Code
X Warranty
(Round to the nearest dollar)
Contract/Agreement Other
for Deed
Quit Claim
7. Are there any mortgages on the property? If "Yes",
outstanding mortgage balance:
$ 0
YES
/ X
NO
Month Day Year
6. Type of Document
8. To the best of your knowledge, were there unusual circumstances to the saleltransfer?
such as: Forced sale by court order? Foreclosure pending? Distress Sale? TItle defects? Corrective Deed? Minerai rights? YES / X
Sale of a partial or undivided interest? Related to seller by blood or marriage?
9. Was the sale/transfer financed?
YES
XI
NO If "Yes" 1 please indicate type or types of financing:
I'\greement or
Contract for Deed Other
InstitutlonaV
Miscellaneous Govemment
Agricultural
Vacant
Acreage
Timeshare
Conventional X
Seller Provided
10. Property Type: Residential
Mark (x) all
that apply X
11. To the best of your knowledge, was personal property
Included in the sale/transfer? If "Yes", please state the YES I
amount attributable to the personal property. (Round to the nearest dollar)
Commercial
Industrial
X NO
$
12. Amount of Documentary Stamp Tax
13. If ~ is due in number 12, is deed exempt trom Documentary Stamp Tax under s. 201.02(6), Florida Statutes? YES I NO
Under penalties of perjury, I declare that I have read the foregoing retum and that the facts stated in It are true. If prepared by someone other
that the. taxpayer, his/her declaration Is based on ormation 0 hlch he/ he has any knowledge.
Signature of~or Grantee Agent Date 04/17/06
WARNING: FAILURE TO FILE THIS RN OR ALTERNATIVE FORM APPROVED BY THE DEPARTMENT OF REVENUE SHALL RESULT IN A
PENAL TV OF $25.00 IN ADDITION TO ANY OTHER PENAL TV IMPOSED BY THE REVENUE LAW OF FLORIDA.
'$
263.20
(To be completed by the Clerk of the Circuit Court's Office)
Clerk's Date Stamp
O.R. Book
and
Page Number
and
File Number
Date Recorded I
Month Day Year
COPY TO DEPARTMENT OF REVENUE OFFICE
COPY TO PROPERTY APPRAISER
"...
Closing Agreement
The undersigned, City of Clearwater ("Seller'') and Grant A.J. Boshoff and Venussa
Boshoff ("Buyers'') agree as follows:
1. COOPERATION. If requested by the Closing Agent, both parties will fully cooperate in
correcting any clerical or typographical errors on any closing documents. It is understood that
the office of Freedom Title Agency, Inc., as Closing Agent, and the lender will rely upon this
agreement in closing this transaction.
2. ASSESSMENTS AND TAX PRORATIONS. If the property involved is a subdivision lot
or a condominium, the property may be subject to assessments levied from time to time by the
subdivision or condominium association. If any such assessments are prorated on the closing
statement for this sale transaction, Seller warrants and represents that Seller has nQ information
that the actual regular or special assessments are different than shown on the closing statement.
If no assessments are prorated on the closing statement, Seller warrants and represents that Seller
knows of no assessments on the property. If, after closing, Buyer pays any assessment for any
time period prior to closing, Seller agrees to reimburse Buyer upon demand for any such
expenditure unless otherwise provided in the contract between the parties.
The Closing Agent relies upon information supplied by the Condominium or Homeowners
Association or the Seller and shall not be liable for any inaccuracy in the information supplied.
If the most recent property tax bill was issued in the year preceding the closing date, then the
tax prorations set forth in the settlement statement are based upon an estimate. The basis of
proration as set forth on the settlement statement is hereby accepted by the parties to this
transaction. It is hereby understood and agreed that the actual taxes, if different, will be adjusted
between the parties upon demand if re-proration is provided for in the contract between the
Buyer and Seller. Closing Agent is not liable or responsible for adjustments or re-prorations of
taxes. Closing Agent is not responsible or liable for additional taxes, other charges or tax
refunds, if any, and shall not be liable should any of the parties to this transaction fail or refuse to
re-prorate the taxes.
3. REPRESENTATIONS. Closing Agent does not make any representations or warranties
nor assumes any liability with respect to the physical condition of the property, or any repairs to
the property or any damages thereto regardless of the cause. Buyer has been advised and
encouraged to secure insurance coverage appropriate to the property and various inspections of
the property prior to completion of closing. Buyer has received and reviewed the inspection
reports, if any and this shall confirm that Buyer has accepted the property knowing of the
disclosures in the reports.
4. SURVEY. If a survey was prepared for the subject transaction, then the Buyer hereby
acknowledges receipt of a copy thereof. The Buyer has reviewed said survey and accepts title
subject to the matters set forth thereon.
5. TITLE. Buyer has received and reviewed the proposed deed and is satisfied with and
approves the manner which title is being held.
6. UTILITIES AND SERVICE CONTRACTS. Closing Agent does not adjust or assume
liability for charges for water, rents, gas; electricity, taxes on personal property, garbage taxes or
fees, license fees or taxes, service/maintenance contracts (pest control, appliance maintenance, pool
care, lawn care, alarm systems, etc.).
7. SETTLEMENT STATEMENT. The settlement statement has been reviewed and approved
and Closing Agent is irrevocably authorized and directed to complete the closing of the transaction
and make disbursement in accordance therewith. In the event of mortgage assumption, if Seller has
received a credit for the escrow account balance, then Seller hereby assigns all right, title and
interest in said account to Buyer.
-,~
.
8. RECORDING FEES. Purchaser also acknowledges that Clerk of Court recording fees are
estimates and when the final recording fee is determined it may be less than, or more than, the actual
cost, however, overages will not be refunded and shortages will not be collected.
9. DISCLOSURE. Closing Agent does not disclose any nonpublic personal information about
the parties to anyone for any purpose that is not specifically permitted by law.
10 CLOSING AGENT. This Agreement is being provided as an inducement for Closing Agent
to serve as the closing agent and for Title Agent and Title Underwriter to issue title insurance on the
subject transaction and shall survive the closing.
Executed this 2.'2~ day of ~O ~ 2 . 2006
~-5
rant A.J~ SosholI ____________
0~~<#A~
Venussa Boshoff
~~
City of Clearwater by Earl Barrett,
Real Estate Services Manager
~
~-,
OWNER'S AFFIDAVIT
NON-FOREIGN CERTIFICATE
AND
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
STATE OF FLORIDA
COUNTY OF PINELLAS
BEFORE ME, the undersigned authority, personally appeared Earl Barrett" of City of Clearwater (the
"~~"), ("Seller" refers to ~~gular or plural as context requires) who, first being duly sworn, deposes and says: ~ 10
TTf.,e. /3"si 9 T If/SO ;t"~Ua:J;e -
A. OWNER'S AFFIDAVIT
1. Seller is the owner of the following described property (the "Property"):
The South 50 feet of Lots 1 and 2, Block H, PLAZA PARK, according to the map or
plat thereof as recorded In Plat Book 5, Page 53, of the Public R'ecords of
Hillsborough County, Florida, of which Pinellas County was formerly a part.
Property Address: 501 Pennsylvania Avenue, Clearwater, FL 33755
2. There is no outstanding contract for the sale of the Property to any person or persons whomsoever, nor any
unrecorded deed, mortgage or other conveyances affecting the title to the Property.
3. There are no liens, encumbrances, mortgages, claims, boundary line or other disputes, demands or security interests
in, on or against the Property or any goods, furnishings, appliances, fixtures or equipment now installed in or which are to
be affixed to the Property; except for mortgages described in the deed given by the undersigned; that there are no unpaid
taxes, levies, assessments, paving liens or utility liens against the Property (other than real estate taxes for the current
year).
4. That there have been no Improvements upon the Property within the past ninety (90) days for which there remain
any outstanding and unpaid bills for labor, materials or other charges for which a lien or liens might be claimed by anyone
whomsoever.
5. That there are no matters pertaining to the Seller which could give rise to a lien that would encumber the Property
during the period of time between the effective date of the Title Insurance Commitment and the time of recording of the
Warranty Deed and that the Seller has not executed and will not execute any instrument that would adversely affect the
title to the Property from the date of the Affidavit forward.
6. That there are no judgements, claims, disputes, demands or other matters pending against Seller that would attach
to the Property. Seller has complied with the Florida Sales Tax laws where applicable. Seller acknowledges responsibility
for water, sewer and electrical consumption charges through date of closing or occupancy by Buyers, whichever first
occurs.
7. Seller is in sole constructive or actual possession of the Property and no other person has any right to possession
of the Property, or asserts any claim of title or other interests in it.
8. Seller represents that there are no violations of governmental laws, regulations or ordinances pertaining to the use of
the Property.
B. NON-FOREIGN CERTIFICATE AND REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
Section 1445 of the Internal Revenue Code provides that a Transferee ("Buyer") of a U.S. real property interest must
withhold tax at a rate of 10% of the amount realized on the disposition if the Transferor ("Seller") is a foreign person. To
inform the Buyers that withholding of tax is not required upon the disposition of a U.S. real property interest by the Seller,
the undersigned hereby swears, affirms and certify(ies) the following as or on behalf of the Seller:
1. Seller's Legal Name is: City of Clearwater.
2. Seller's Home Address or Office Address if Corporation, Partnership or Trust:
100 S. Myrtle Avenue, #220, Clearwater, FL 33756
......,..~
.
3. Seller is not a non-resident alien (if individual) or a foreign corporation, foreign partnership, foreign trust or foreign
estate (as those terms are defined In the Internal Revenue Code and Income Tax Regulations).
4. That the amount realized by the Seller (Transferor) of the above-described real property as a result of this
transaction does not exceed Three Hundred Thousand ($300,000.00) Dollars.
In connection with the sale or exchange of the Property you are required by law to provide FREEDOM TITLE
AGENCY, INC. with your correct taxpayer identification number (TIN). If you do not so provide your TIN, you may be
subject to civil or criminal penalties imposed by law.
5. Seller's Taxpayer Identification Number:
City of Clearwater
6. For purposes of reporting this transaction to the Internal Revenue Service on Form 1099-S, the .Property is Seller'
(check one):
D
This taxpayer identification number is being provided In connection with a real estate transaction.
The undersigned understands that this Certificate may be disclosed to the Internal Revenue Service by the Buyers and
that any false statement contained herein could be punished by flOe, imprisonment or both.
Under penalties of perjury, I/we declares that I/we have examined this certification and to the best of my knowledge
and belief it is true, correct and complete, and I/we further declare that I/we have authority to sign this document as or on
behalf of the Seller, and that the number shown on this statement is Seller' correct TIN.
Seller states that this instrument is given for the express purpose of inducing Grant A.J. Boshoff and
Venussa Boshoff, husband and wife to purchase the Property and to cause FREEDOM TITLE AGENCY,
INC. as agent for Old Republic to insure title to said property. This Affidavit is made under the full understanding of
the law regarding liability for any misrepresentation herein.
City of Clearwater
BY'~
Earl Barrett,
By:
STATE OF FLORIDA
COUNTY OF PINELLAS
The foregoing instrument was acknowledged before me this~ ~f April, 2006 by Earl Barrett, of City of
Clearwater on behalf of the corporation. He/she is personally known to me or has produced
as identifICation.
SEAL
..11'"', HELGll. RUENNt:
i~m~>!!v P"~~ Notary PubHc - Stale of Florida
~. · : . i My Commission Expires Jul19, 2009
\~ if/ Commission # DO 452691
"'~,?r.f.~,,'" Bonded By National Notary Assn.
FILE NO: 06-2490