HomeMy WebLinkAboutL 12287 P 241
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CONSULT 'YOUI LAWY.I I.POI.IIGNIN. tMll.INITIU"INT-THII INlftUMINT SHOULD" UII. IT LAWYIU ONLY.
THIS INDIN'I1JJU!, mod. the 24th clay of. November, 2003
IErWI!EN
CATHERINE SMITH a/k/a CATHERINE E. SMITH and SUSAN SMITH
a/k/a SUSAN M. SMITH, as Joint Tenants with Right of
Survivorship
Both residing at 148 Bayview Avenue, Port Washington, NY
11050
pany of ttie first ~rt, and
CATHERINE SMITH a/k/a CATHERINE E. SMITH
Residing at 148 Bayview Avenue, Port Washington, NY '1050
pany of the. MCOnd part.
WlI"NE'.5IE"IH that the party of the fint part. in consider.uioll of ten dollan paid by the s-rty of lhe lecond
pary. doa hereby remile. rdeue and. quitc:laim un.to the party of the I<<~' part. the heir. or l\lCCcsson and
--18M of the pany of the aecond pan forever, .
ALL that cenaia plot. piece or- pan:cl of Jand. with the buildiIlC.. aDd impt'overnenb thr.reon erected. situate.
lying and beinc in the .
56 ATTACHED SCHEDULE A.
nee with an Order of the
hereto), dated 11/1~/03,
sau County Clerkls Office
-....
TOGETHER with aU richt. title: and interest. if any. of the party of the fir.t part in and to any street.. and
road. abuttin. the above deKl'ibed premise. to the: center lines thrrcof; TOGI:.-rHER with 1he 3ppurtenancu
and all the atatc and richts of the party of the first part in and to said premises; TO HAVE AND TO
C(i\ uflOL.D.the premises.her.~i!1l',:an"t.!.d unto the patty of the aecond part, the hein or succeuo... and assicns of
JI,~.party of the ~~part fore~r.
L' ,
11' ;':tl' ~. . . ..'h~
AN-D'th'e party of tbe tint p;.rt. in compliance with Section 13 of the Lie~ Law. hereby covenantlthat the panr
of the firat pAn vUU'rcceive the conlideratioa. for this conveyance and will hold the richt to rec:c-i,'e .ucIl conaid-
eratioa .. . trUlt fund to be applied-lirlt for the purpoIC of payine the cosi: of the improvement 2.nll will -Pr,ly
the aame fint to the paymell;lt of the co.! of the improvement before ulin&: any part of the tOCaJ of thl: same for
any-~. .
The word ..party" shall be construed. .. if it read ....rti... whcacver the acniC of this indenture 80 requires.
IN ~ WHII'."OP, the party of the fint part has duly executed tm deed the: day and. year fint abo\"e
writtaL
bn~"h-" DO, E' L ,,' P'.
Catherine Smith a/k/a -: .
Catherine E. Smith
h",,, Ai' ~'*~~C' I-..~
Susan Smith a/k/s a- .:./e --,
15usaq M. Smith
By Catherine E. Smith, as
Guardian for the P s &
Property of Susan ';f. 'MI.n:h, .IP
I. ........c. ow:
,~.l3~ ~rC.ttAA.
- -.,..'t~";.~-''''''''~'1::~~...'..
~ IN '-YORk STAT. eII"- aae..J
St.lle of New York, County 01 Nassau ...:
On 11/24/03 bef"", me, .... andeniallOd,
penonollY_8IM Catherine E. Smith
peI'IOI1IIJy known to me or proved 10 me an.. bull of....ilfK'~
rory ev_ 10 be lhe --CI) wbaoe"IIIIIIO(.) is ClIO)
_10"'" _ill _,11M! -..owIedpd 10 me lIIII
bdobaIIIIey __ "'" ume In hla'herfllleir capoc\Iy(la),
_ _by h_ir~I)'" ""'. indi-
viduoI(l). or "'" _ _. idua1CI)
_ CUClI1ed "'" I
,
JOHN G.
Notary Public ..e
No.02 AS
Qu.lifiad In :!IS
CommISSion Eapir
--
S_aI
On
........lIy _81M
pIDOII8Dy known to me or proved CO me ad rhr: bais of llIIi..
fOCl<lly ..- 10 be lbc indivklualCI) _ 11lIIIO(1) is ClIO)
aabacribed ID the within instrument. and acImowleqed 10 me
dloI....lllelllleyc_dle.ameilllri_Ir~Ic.I).
ODd ..... by IdaIbedlhcir Upoluft(.)... IIlc inIlnI_~ .... iadi-
vlduaI(s}. or "'" _ upm beholf or wbiclt lbc 1ndMdua1(.)
_ _ lbc inIIIu_ IIIId _ oudI iadivimal ..-
mcb --rr __ before Ibe: underaianed in
(...."dI)'-poIIIItwI...........--__~orGllwr",.u~
--
(~.".,oJIb",~..... """1.4-_ 4J
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(futtdabn ..rilI
1m. Ca""'AIft ACM:1Ift c.,,1mM'a Acra
TrrLB NOfi
CATHERINE E. SMITH
SUSAN M. SMITH
TO
CATHERINE E. SMITH
.
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~1h''''UCR_llIwm --E"]
sa.a. 01
County of
10..:
On
pcl'oonolly oppeared
before me. Ibe undenipd.
die lut.crlbiftl wlUlelI(ell) to Ibe fenloilll IIlIbUmc.nt, wllb
w....... I un pcrMmally acqaaiDll<d, wllo. bel.. by me duly
lworn. did depoee and say Ib.u. heI&heIlbe,. rakle(l) In tV-
,~ ." ,.~ u I_ . riI7, 1Itcl.. ... ~ fIfttl II'"' _.-Hr.
If...", ''--A:
Ill.. .....sIleIdley -C.)
10 be me indlvlduolC.) deocribcd In and who eucuMod ..... rare.
aoina iDllnlmenl; ..... said oubocnbl.. ..;1nCa(0I) woo C-.o)
_'_lOW said. -
eaecull: die AIDe; and that aaid wlUll'U(n) at the same lime
_ribcd hillberllllcir namc(1) U 0 wllDOll(ca) Ill...,....
([J U--......,.. Brisw. """"dIy.,,...., ............._
""~"'__,*"_~. ~ 11..... ADd......8id..Al-..Jbb..
W~OI) made oucb ....--.'" bel'ore lhe a_pod in
1
t.....""..." t/fIIIn -:/".."..'..... _..4 .11
SECTION "1.26
IILOCI< 1 0
LOr 15
00UIn'Y Oil 'I'OWN Suffolk
II&'I'UJIJI BY IlAIL TO.
John G. Dalton, Jr., Esq.
12 Monfort Road
Port Washington, NY 11050
Zip No.
.. .... .,.
SCHEDULB A
ALL that certain plot, piece or parcel of land, with the
buildings and improvements thereon erected, situate, lying and
being at Laurel, in the Town of Southold, county of Suffolk and
state of New York, being bounded and described as follows:
BEGINNING at a monument set on the northwesterly line of
peconic Bay Boulevard which monument is north 42 degrees 01
minutes east 100.00 feet from a monument set at the intersection
of the northwesterly line of Peconic Bay Boulevard with the
easterly line of the land now or formerly of Dr. Martin and which
monument is also north 42 degrees 01 minutes east 220.76 feet
from a monument set at the intersection of the northwesterly line
of peconic Bay Boulevard with the boundary line between the lands
now or formerly of Thomas H. Harper and now or formerly of
Charles F. Lewis and running thence from said point of beginning
northerly and northeasterly along land of Bllen Hinsch, the
following two courses and distances: (1) northerly 18 degrees 54
minutes 10 seconds west 202.29 feet to a monument; (2) northerly
42 degrees 01 minutes easterly 100.00 feet to a monument set in
the westerly line of land of S.T. Mackenzie; thence southerly 18
degrees 54 minutes 10 seconds easterly along land of S.T.
Mackenzie, 202.29 feet to a monument Bet on the northwesterly
land of peconic Bay Boulevard thence southerly 42 degrees 01
minutes west 100.00 feet to the point or place of BEGINNING.
TOGBTHER with an easement for passage on foot to be used in
common with others entitled to use same, over a certain Right of
Way 25 feet in width adjoining other property formerly owned by
Jesse E. Kahn at Laurel, Town of Southold, County of Suffolk and
State of New York, bounded and described as follows:
BEGINNING at a point on the southeasterly side of peconic
Bay Boulevard where the same is intersected by the westerly side
of land now or formerly of Booth; running thence along said land
now or formerly of Booth south 19 degrees 42 minutes 40 seconds
east 341.05 feet to peconic Bay; thence along the same south 40
degrees 05 minutes 30 seconds west 21.94 feet to land now or
formerly of Jesse E. Kahn; thence along said land north 20
degrees 18 minutes west 340.04 feet to the southeasterly side of
peconic Bay Boulevard thence along the southeasterly side of
peconic Bay Boulevard north 42 degrees 01 minutes east 25.48 feet
to the point or place of BEGINNING.
Being the same premises conveyed by Andrew L. Reilly to
Catherine Smith and Susan Smith, as joint tenants and not as
tenants in common with right of survivorship and to the heirs and
assigns of the survivor forever, by deed dated September 4, 1970,
and recorded on 9/15/1970 at the Suffolk County Clerk's Office in
Li~er,6807; and pag~' 126.
Said premises also known as 7025 peconic Bay Boulevard,
Laurel.. New York.
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At IA Part 26 of the Supreme
Court of the State of New
York, held in and for the
County of Nassau, at 100
Supreme Court Drive, Mineola,
New York, on the I~ day
of ~ ,2003
PRE S E N T:
H 0 N: Anthony F. Marano
Justice
-------------------------------------x
l[n the Matter of the Application of
Catherine E. Smith,
ORDER TO TRANSFER ASSETS
OF.THE INCAPACITATED
PERSON'
iLS Guardian for
SUSAN M. SMITH,
Index No. 269S3-I-2002
An Incapacitated Person.
-------------------------------------x
.
The petition in writing, duly verified the sth day of
()ctober, 2003, by the petitioner therein named, having been
presented to this Court wherein it is requested that the assets
()f Susan M. Smith, an Incapacitated Person, pursuant to Mental
Hygiene Law Section Sl.21 be transferred to her sister, the
Guardian and tbe Petitioner, Catherine E. Smith, and the request
being made (i) transfer of the interest of Susan.M. Smith in real
property at 7025 peconic Bay Blvd., Laurel, New York, [H)
transfer of JO~ Hancock Annuity #BK 1120602, (Hil transfer of
1,634 shares of Merrill Lynch stock and further, it being
:requested that 417 shares of Merrill Lynch stock of Susan M.
:Smith be transferred to St. Peters Roman Catholic Church, Port
I
Washington, New York, and the Court, by Order to Show Cause
granted October 8, 2003, having required notice of the
presentation of said petition to be given to Susan M. Smith,
Catherine E. Smith, Michael P. Smith, Jr., Lawrence P. Smith,
Thomas R. Smith, Patrick J. Smith, Nanette Smith, Marianne Smith,
F:rank smith, Margaret Hutcheson, Patricia S. Rocks, Elizabeth
Redding, Katie Gent, Joseph Duffy Smith, and to John Newman,
Esq., the Court Examiner, Nassau County Department of Social
services, St. peter of Alcantara Roman Catholic Church, and the
Hanover Insurance Company (Guardian Bond) and proof of service
upon each of the aforesaid respondents having been duly filed,
I
I
(
.
i
I
I
and
The Court having thereupon considered said petition then and
there .presented, and a hearing having been held on the 5'. day of.
,.
November, 2003, and John G. Dalton, Jr., Esq., having appeared
for Catherine E. Smith, the petitioner, and on the reading and
filing the recommendations of John Newman Esq., the Court
Examiner appointed herein,
AND upon the evidence presented at the aforesaid hearing,
AND there being no obj~ction,
AND it appearing to the satisfaction of this Court, by clear
and convincing evidence, that the Petitioner meets the criteria
set forth by Section 81.21 of the Mental Hygiene Law regarding
transfer of assets and the substituted judgment doctrine
regarding transfer of assets is appropriate here, and the Court
f'inding that the natural object of Susan's bounty would be her
sister, Catherine, who'S been the loving and caring sister that.
2
I
, ,
, "
~as resided with her for the last thirty years; been her friend,
cl~mpanion and now health aid with respect to her sister, and upon
all the aforementioned papers heretofore filed herein, the
e'vidence adduced, and the d.e'ciBion of this Court rendered on the
r,ecord on November 5, 2003, and after due deliberation,
NOW, on motion of John G. Dalton, Jr., Bsq., Attorney for
the petitioner, it is
ORDBRED AND ADJUDGBD, that in respect to the real property
in Laurel, specifically 7025 peconic Bay Boulevard, Laurel, New
York, that the Guardian shall be authorized to transfer Susan M.
Smith's fifty (Sot) percent interest in such premises to
Catherine B. Smith, and. it is further
ORDBRBD AND ADJUDGBD, that in respect to the annuity in John
Hancock IBK 1120602, the Guardian is authorized to transfer such
annuity from Susan M. Smith to Catberine B. Smith, and it is
further
ORDBRED AND ADJUDGBD, that in respect to the shares of
Merrill Lynch stock, 'the Court is authorizing a transfer of 1,634
shares of Merrill Lynch stock from Susan M. Smith to Catherine B,
S,mith, and it is further
ORDBRED AND ADJUDGBD, that in respect to the shares of
Merrill Lynch stock, the Court is authorizing a transfer of 417
shares of Merrill Lynch stock to St, Peters Roman Catholic Church
i,n Port Washington, New York, and it is further,
ORDERBD AND ADJUDGBD, that the Court is authorizing the
transfers of stock effective immediately, and it is further.
ORDERBD AND ADJUDGBD, that the Guardian shall pay from the
3
t
,
..
. --- ~
E~s of the Incapacitated Person, the following disbursements:
To John G. Dalton, Jr., Bsq, the Petitioner's attorney, the
sum of $ ~ ~OO ~ , as and for any and all services
,
:~endered in thi,s proceeding, including for serving as Attorney for
the Petitioner through the conclusion of this matter, and the sum
c)f $ 4'!.D. kt.
for disbursements.
BNTBR
J.B.C.
ENTERED
Nal 1 B III
'NASSAU COUNTY
COUNTY CLERK'80Fa
COUII'I'Y CLl!IUI:'S 07nllB }
B'l'ATB or NIlW YORK, B8:
C01IlI'l'Y or IIA88AU
1, K.... V. II....... 0Ia'1< 01 UIe CouD\;I' 0111_ ond of UIe
BuJINIIIII aDd CouDI7 cou.... CDu... al_, do _, 00I'U1711la1 ha"
oomparocl UIe aD_ WlUl Lbo arlClnoI OIlDBII rlLIlID AIID ~D In
my oflIl:o, . .. .. .. :t1'4!.. tr, .~'IU .. .... aDd Ulol UIe oomo la 0 IruO
~P' Ulorool. ond of till .bala of ouch artClDoI.
In TeoUmanr WIlorool. I hO'l!JlorlU1ISG 01'1111 h&Dd &D4 otlIzed UIe
-.::---;7~~~
4
.-..... ',-.
NUlllhL-r or Imgcs
TORRENS
~
RECORDED
2003 D~ 01 04:02:28 ?~
Edward P,~~~ai~
CL-"RK OF
stF'FOLK COUtfiY
L 000012287
P 241
OTl 03-10083
Scriul :#
Ct.:rtilicalc"
Priur elr. #
Deed I Mnrtp:age Instlument
I"=eLl I ~lJrtgngc "l"a.1( Slump .
FEF.s
Reconling I Filing Stamps
2J
R.I'.T.S.A.
.{lrf"/
Mongogc Allll.
J. BlLo;ir.: Tax
2. AddiLiollal Tax
Sub Total
Spec.l Assit.
IIr
Spec. I Add.
TOT. MTG. TAX
Dual Town _._ Duul Counly _
Held fur Appoinlment
Trnn.lC" Tax - a--
Mansiun T:IX
P:I~C I FilinEl Fee
Ihmdling
5.~
TIJ.5K4
NI)llIliOII
r::/"\-52 17 (Cuunly)__
E.'\-.5217 (Slute)
Sub l'i.ltul
CClIIIIII. nrEd.
__~ .!'!L
Amd:1Vit
<"':crlifiL~ COIl1Y
NYS SIIn:lulIrgc
Olher
15. J!\L
'suhl'ul:l.J
'111e proJ'Crty cuvcred by thi~ mortgagc is
or will be 'iml)mved by u oue or two
fumily dwclliug unl)'.
YES ur NO
Or:llul Total
Ir NO, ~,,"'e appropriale lax clause on
p-dgc # ur thi:.; in.~trumcnt ~.
4
Section
03048826 1000 12500 1000 015000
~~
61 S;lti~riU:li(ln!V1)i"cllD.-g~~lRclcu~s List Property Owncn; M~ilillg.^ddres.""
IUtCOIU) & RETURN TO:
Rt'al (lmpclty
Ta~ Scrv ic:.."
Agency
VI...riIiL'ntitJn
Consideration Atnount $
5 Community Preservation Fuud
0-
CPF Tax Que 5
Inlpn)VOO
Vacum LancJ
SOy\-{") G. ~ \-\tn ,-:Sf. I ES'1s .
I' 2.. l-1on~+ fC.ood
PO"i+-tJQSh.vz.:rhn, W " /)!V
TO
TD
TD
Thil\ page fUrl11N pm1 uf Ihe aU.achccJ _
Suffolk County Recording & Endorsement Page
(JPA'"J _
(SPECIFY TYPE or INSTRUMENT)
('"(1-h..~~ i ..., ~ t:.-' The premise... herein is ,.iUlRh,"d in
SUFFOLK COUNTY, NEW YORK.
7
~I
mauc by:
Ca.n..hi\ne S"".:fh .../yu.
~~ .s1uran ~)f..(,~
TO In lhe "filwn.hip of __ Stll...H..i61d
.Ca.ftv?;"/",e S,..,,'.h. '" IAI, In the VILl.AGE
('I'l'fw,nr.p E;. <).-l-h-, urliAMLETur
IJOXI3S Ii THI~U K MlIST 1113 TYPED OR I'RINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FlLlNG.
1111111111111111111111111111111111111111111111111111111
1111111111111111111111111
SUFFOLK COUNTY CLBRK
RBCORDS OFFICB
RECORDING PAGE
Type elf InBtrument: DBEDS/DDD
N'umbe]~ of PageB' 8
TRANSFBR TAX NUMBER: 03-18083
Recorded:
At.
LIBER:
PAGB:
12/01/2003
04.02.28 PM
D00012287
241
SUSAN SKITH
CATHERINE SMITH
Distdct:
1000
Deed AIIIount.
Section. Block:
126.00 10.00
BXAMINBD ANI) CHARGED AS FOLLOWS
$0.00
Lot.
015.000
Received the Pollowing Pees por Above InBtrl.llll8Dt
Exempt lZY'""Ipt
Page/Piling $24.00 NO Handling $5.00 NO
COB $5.00 NO IfYS SRCRG $15.00 NO
BA-CTY $5.00 NO SA-STATB $50.00 NO
TP-584 $5.00 NO Cert.Copies $0.00 NO
RPT . $30.00 NO SCTM $0.00 NO
Transfer tax $0.00 NO COIIIII.Pres $0.00 NO
PeeB Paid $139.00
TRANSFBR TAX NUMBBR. 03-18083
THIS PAGB IS A PART OP TEB INSTRtJMBNT
THIS IS NOT A BILL
Bdward P.Romaine
County Clerk, Suffolk County
PLEASE TYPE OR PRESS FIRMLY WHEN WRITING ON FORM
INSTRUCTIONS: http://www.orps.state.ny.us or PHONE (518) 473-7222
FOR COUIIJTY USE QN:..Y
I~ ?~, ~ g '1;
I / c>(! I ! f) ..21
Month DBV V.....,
g, 11 CU... I <<,'-t, (,
Hp_5217 RevJl97
REAL PROPERTY TRANSFER REPORT
C1. SWIS CDde
*
C2. Datl~ Deed Recorded
STATE OF NEW YORK
STATE BOARD OF REAL PROPERTY SERVICES
RP - 5217
C3. Book 1 /: q', q::
PROPERTY INFORMATION
1.r=:i:~1
70 'd-S
STRHTNUMeER
t-A-uR\:;L
rE.LCl/...; i CD.P<. \j
STREET NAME
_I
IlciWI
ZIP CODE
2. Buyer
Name
sm J T/-i
L^STNAMcl';OMPANY
--AII<-/A
c,uu Li:O\J!'IRD
L ___""~"
I (ATHErZlfc.J(=
SrYln H ,c.tJ." \-\~Im~."t.
I
C'TYOR TOwrJ
L.AST NAMi: I COMPANY
ARSTNAME
3. Tax :nd;cate wnere future Tax Bills are to be serll
Billing 'f other than bUYln address I"tbottom offorml
Addr_
L--
LAST NAME I COMPANV
FIRST NAME
I
S;I\LL1NUMal"AI',D$TREHNAME
CITV OR TOWN
SlAN'
71PCODE
4 Indicate tl..... numb.. of AM_ment
Roll JNIrce,lstransferrlld on thll dlllKl
100
4A. Planning Board with Subdivision Authorrty Exists
I It of PlIrceh; OR D Part of a Parcel
{Only if Part of a Par"lIl1 CheGk as they apply:
\rj e", -.J X I
r"i5N~JfEh
ACRES
.
D
D
4C.ParceIApprovedforSubdivisionwithMlIpP'ovided 0
(',flTHEr<-lrUE A/KIA, 5:011 t~kr.~,1'tIJ
A/KIA S',11/I'11,Scl.SttV) ill.
I
5, Deed
Property
Size
48. Subdivision Approvlll WlIB ReQui'ed for Trnnsler
lOR L
~~1~:J
6. Seller
Name
2>m I T H
lAST ~AMEICOMPANY
SrfllTtt
lAST I;AME t COMPANY
FIRST NAME
FI~ST NAME
S lA <,.'110
7. Chec:k the box below whic:h most ac:curat8ly describes the usa of th. prop.rty at the time of sele:
Check tha box... billow 1111 they apply:
8. Ownership Type is Condominium
9. New Construction on Vacant Land
TOA. Property I oealed withi~ an Agricultural District
tOB. BUYllr roceiVilda disclo/;urtl noticeindiClltin\J
that the property is in an Agricultural D'~t,ict
D
D
D
D
~onerSmilYReSidenlial
R 2{,r3 Fam'ly Re~id"nLiul
C Re,idenliaIVacanll"nd
D\lon.ResrdentiaIVacant Land
E~AgriCultural
F Commercial
G Apartment
H Entertainment! Amusement
~~
CommllnilyServ:Ce
Industriel
Public Service
Foresl
SALE INFORMATION
15. Chfldt one or more of the.. conditions as applicable to transfer:
11. Sale Contrac:t Date
~
MOOlh
Year
A
B
C
D
E
F
G
H
I
J
Sarti BIltw81ln R81atives or Formal' Ralatives
Sale BtItween Related Companies or Partners 'n !:lu5iness
One ofth" Buyers is also II Sellel
Buyer or Soller is Government Allency ur Lcnding Institution
Dead Type not Warranty or Bargain and Sale (Specify Below)
Sale of Fractional or less than Fae Inlerll51 (Specify Below)
Significant Change in Property Between Taxable Status and Sale Dates
Sale of BIJ"in..~ is Included in Sale PriclI
Othllr Unusual Factors Affecting Sale Price ISpecify Below)
None
0.,
12. Date of ~Oale ! Transfer
Ii
24- 103
-"
0.,
Yesr
1 l._-----'-------'--------P.~. 0 I
, , .
(t-~II Sale Prioo is tne toTal amollnt paid for the propenyincluding personal propelly.
This paym,mt may be in the form of cash, other propeny or goods. or The assumption of
mortgages Or OTher obligatio.",.1 PI""!!,, round to (he nearest whole dollar amount.
13 Full Sale Price
&\-\ITr Li\/,'-'I
D<:JO:i)
,-{)-:-o, 0 I
, .
ASSESSMENT INFORMATION. Data should reflect the latest Final Assessment Roll and Tax Bill
14.lndleate the value of pat'sonel
propeTty in&luded In the sele
16. :~~::~n~':=t~;.n:a~:~, from ~ 17. Tota' As8essed Value (of all pa.-celli in transferl I
'-C57 '11
,
18. Property Class
J 10 0\
lE~J-[._J 19. School OilltrlctNam. I
l,-"ure\
20. Tax Map Identifier(sll ROllldentifier(sl IIf mo.. than four, aUsch sheet with addition81 id.ntifi.r{.ll
IO.CO-IOlGc,-- ID - is-
~ 1:~ ],_
L--
ICERTIFICAllON
I certify dllt~ all of the Items of Inronnation entered on tlU!i form are true lU1d correct (to the best of my knowledgo. and heUeO :and I understand that the making
lOr an}' willfull false s....l..m'ml of material fact herein wiD subject me to the Ilrovt~lon~ of the penal law relative to the milking and filing of false instruments.
BUYER'S ATTORNEY
/ BUYER f 4
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