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INSTRUCTIONS: http://www.orps.statemy.us or PHONE (518) 473-7222 KI
FOR tAJ
: U1a1 SWISY USE ONLY" . w
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5 ( i. REAL PROPERTY TRANSFER REP RT
STATE OF NEW YORK
` STATE BOARD OF REAL PROPERTY S R ICES
C2.Dato
y i $� RP - 5217
C4 is txCEL I RP-5217 Rev 3/97
PROPERTY INFO
1.Property I 1 y'3 I Afta Street I
Location STREET NUMBER STREET NAME
Southold I Gng- _rt I 1194 . I °
CITY OR TOWN VILLAGE ZIP CODE
- 3
2.Buyer I �ISEMSTEIN I 11ELW I
Name LgST NAME/COMPANY FIRST NAME
T .
LAST NAME/COMPANY FIRST NAME '
3 Tax, ; :Indicate where future Tax Bills are to be sent I I
thl6rtg if other than buyer address(at bottom of form) I
LAST NAME/COMPANY FIRST NAME
I I I I I
STREET NUMBER AND STREET NAME CITY OR TOWN STATE ZIP CODE
4.Indicate the number of AssessmentII ►► II ❑ (Only if Part of a Parcel)Check as they apply:
Roll parcels transferred on the deed I� #of Parcels OR Part of a Parcel
4A.Planning Board with Subdivision Authority Exists ❑
5.Deed r 4B.Subdivision Approval was Required for Transfer ❑
Property I I X I I OR I 4C.Parcel Approved for Subdivision with Map Provided ❑
Size FRONT FEET DEPTH k ACRES
6.Seller I tiUER I J&PF JOSEPH I
Name LAST NAME/COMPANY FIRST NAME
LAST NAME/COMPANY FIRST NAME
7.Check the box below which most accurately describes the use of the property at the time of sale: Check the boxes below as they apply:
8.Ownership Type is Condominium ❑
A One Family Residential E Agricultural I Community Service 9.New Construction on Vacant Land ❑
B 2 or 3 Family Residential F Commercial J Industrial 10A.Property Located within an Agricultural District ❑
C Residential Vacant Land G Apartment K Public Service 10B.Buyer received a disclosure notice indicating ❑
I - Non-Residential Vacant Land H' Entertainment/Amusement L Forest that the property is in an Agricultural District
15.Check one or more of these conditions as applicable to transfer:
11.Sale Contract Date I 8 / 4 / 99 I A Sale Between Relatives or Former Relatives
Month Day Year B Sale Between Related Companies or Partners in Business,
C One of the Buyers is also a Seller
12.Date of Sale/Transfer 1 11 / 10 199 1 D Buyer or Seller is Government Agency or Lending Institution
Month Day Year E Deed Type not Warranty or Bargain and Sale(Specify Below)
F Sale of Fractional or Less than.Fee Interest(Specify Below)
G Significant Change in Property Between Taxable Status and Sale Dates
13.Full Sale Price I 4 51 , a , 0 .0 C) 0 H S e of Business is Included in Sale Price
7 7 •
(Full Sale Price is the total amount paid for the property including personal property. I Other Unusual Factors Affecting Sale Price(Specify Below)
This payment may be in the fbrm of cash,other property or goods,or the assumption of J None
mortgages or other obligations.) Please round to the nearest whole dollar amount.
14.Indicate the value of personal
property included in the sale 1 0 I
7 7
16.Year of Assessment Roll from
which information taken 17.Total Assessed Value(of all parcels in transfer)
18.Property Class 19.School District Name
20.Tax Map Identifier(s)/Roll Identifier(s)(if more than four,attach sheet with additional idenoor(s))
1001-007.00-04.00-021.000 I I I
p
I certify that all of the items of information entered on this form are true and correct(to the best of my knowledge aud.belief)and I understand that the making
of any willful false statement of material fact herein will subject me to the provisions of the penal law relative to the malting and filing of false instruments.
YE BUYER'S ATTORNEY
_ Martin I Unda
BUYER SIGNATURE DATE. f LAST NAME - FIRST NAME
HETiM d i&I A. IN
(j --4 .--'`t"� � 914 1 232.09OU
- STREET NUMBER STREET NAME(AFTER SALE) AREA CODE TELEPHONE NUMBER
i`
, i
CITY.-OR TOWN STATEIPC�—
SELLER CIT •. �SOR
k ( r Cop
SELLER SI NATU i., DATE"
JEFF J
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