HomeMy WebLinkAboutL 12834 P 404 EmmEmmEmmEmmEmmommmEmm
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SUFFOLK COUNTY CLERK
RECORDS OFFICE
RECORDING PAGE
Type of Instrument: DEED Recorded: 09/29/2015
Number of Pages: 9 At: 02 : 45:02 PM
Receipt Number : 15-0133314
TRANSFER TAX NUMBER: 15-06124 LIBER: D00012834
PAGE : 404
District: Section: Block: Lot:
1000 017.00 01 .00 011 . 005
EXAMINED AND CHARGED AS FOLLOWS
Deed Amount: $2 ,000, 000 . 00
Received the Following Fees For Above Instrument
Exempt Exempt
Page/Filing $45 . 00 NO Handling $20 . 00 NO
COE $5 . 00 NO NYS SRCHG . $15 . 00 NO
EA-CTY $5 . 00 NO EA-STATE $125. 00 NO
TP-584 $5.00 NO Notation $0.00 NO
Cert.Copies $0 .00 NO RPT $60.00 NO
Transfer tax $8, 000 .00 NO Mansion Tax $20 ,000.00 NO
Comm.Pres $37, 000 .00 NO
Fees Paid $65,280.00
TRANSFER TAX NUMBER: 15-06124
THIS PAGE IS A PART OF THE INSTRUMENT
THIS IS NOT A BILL
JUDITH A. PASCALE
County Clerk, Suffolk County
i
1 2
RECORDED
Number of pages 2015 Sep 29 02:45:02 PM
JUDITH A. PPSCALE
CLERK OF
This document will be public SUFFOLKCOUNTY
L DLKO12834
record.Please remove all p 404
Social Security Numbers DT# 15-06124
prior to recording.
Deed/Mortgage Instrument Deed/Mortgage Tax Stamp Recording/Filing Stamps
3 FEES
Page/Filing Fee aa/0 Mortgage Amt.
_9)
/.çorj
1.Basic Tax
Handling 20. 00
2. Additional Tax
TP-584 fET Sub Total
Notation Spec./Assit.
or
EA-52 17(County) ` Sub Total Spec./Add.
EA-5217(State) TOT.MTG.TAX
R.P.T.S.A. O ",i•��n , Dual Town Dual County
I)', Held forAppointment y�
Comm.of Ed. 5, 00 5. 1 T'* Transfer Tax g,COO i✓
") �- _;I n " Mansion Tax �e7/ezD
Affidavit
Certified Copy '_ 4 The property covered by this mortgage is
or will be improved by a one or two
NYS Surcharge 15. 00 family dwelling only.
Sub Total YES or NO
Other
DM
Grand Total If NO, see appropriate tax clause on
page tf of this instrument.
, PZ.-- I 0 ,3-/SIC
4 Dist.1000 15027164 1000 01700 0100 011005` 5 Community Preservation Fund
Real Property P T iiiiiiinkill11111
1111111 11111I1111`11111IIIII Consideration Amount$Q4206,1,0,-• Q.,
Tax Service SMI '°` IlIlllll1lfll� CPF Tax Due $ 3 7°°C� U�
Agency
Verification
25 -15
_ _�__. — ---- --- J Improved /-"-----
Satisfactions/Discharges/Releases List Property Owners Mailing Address
6 RECORD&RETURN TO: 7
Vacant Land
PATRICIA C. MOORE, ESQ.
5102 MAIN ROAD TD /d
SOUTHOLD, NY 11971
. TD
TD
Mail to:Judith A.Pascale,Suffolk County Clerk 7 I Title Company Information
310 Center Drive, Riverhead, NY 11901
www.suffolkcountyny.gov/clerk Co.Name �j�jJ�JCAS �BsjerJC%
Titlett �JA, (9E 94i
s Suffolk County Recording & Endorsement Page
This page forms part of the attached DEED made
by: (SPECIFY TYPE OF INSTRUMENT)
MARK STEPHENSON TWEEDIE,Individually and as Trustee The premises herein is situated in
SUFFOLK COUNTY,NEW YORK.
TO In the TOWN of SOUTHOLD
GENTLEMAN'S RIDGE, LLC In the VILLAGE
or HAMLET of ORIENT
BOXES 6 THRU S MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING.
(over)
I CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT-THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY
THIS INDENTURE,made the/6day of September,2015
BETWEEN MARK STEPHENSON TWEEDIE, Individually, as to an undivided 50% interest and MARK
STEPHENSON TWEEDIE as Trustee for the benefit of David Scott Tweediewho acquired title under the Last
At
Will and Testament of Dnna Stephenson Tweedie,deceased, Surrogate's Court of the County of Suffolk, File
opII #2013-553,residing at 95 Car;eu Avenue,Huntington,NY 11743195i o 4.i t).0,v'9r f 5I7 t
party of the first part, and GENTLEMAN'S RIDGE, LLC, with office at 404 West 45th Street, New York, NY
10031
party of the second part,
WITNESSETH, that the party of the first part, in consideration of TWO MILLION and no/100ths
($2,000,000.00)dollars paid by the party of the second part,does hereby grant and release unto the party of
the second part,the heirs or successors and assigns of the party of the second part forever,
SEE SCHEDULE"A"ANNEXED HERETO AND MADE A PART HEREOF
TOGETHER with ail right,title and interest,if any,of the party of the first part in and to any streets and roads
abutting the above described premises to the center lines thereof;TOGETHER with the appurtenances and all
the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the
premises herein granted unto the party of the second part,the heirs or successors and assigns of the party of
the second part forever.
AND the party of the first part covenants that the party of the first part has not done or suffered anything
whereby the said premises have been encumbered in any way whatever,except as aforesaid.
AND the party of the first part, in compliance with Section 13 of the Lien Law,covenants that the party of the
first part will receive the consideration for this conveyance and will hold the right to receive such consideration
as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same
first to the payment of the cost of the improvement before using any part of the total of the same for any other
purpose. The word "party"shall be construed as if it read "parties"whenever the sense of this indenture so
requires.
IN WITNESS WHEREOF,the party of the first part has duly executed this deed the day and year first above
written.
IN PRE CE OF ,. 3:1,--tek"
+�J MARK STEPHENS TWEEDIE
MARK STEPHENS N TWEE IE,as Trustee
TO BE USED ONLY WHEN THE ACKNOWLEDGMENT IS MADE IN NEW YORK STATE
State of New York,County of Suffolk ss: State of New York,County of ;AF b1 ss:
On the/S day of September in the year 2015 On the/•s day of September in the year 2015
before me, the undersigned, personally appeared MARK Before me, the undersigned, personally appeared MARK
STEPHENSON TWEEDIE STEPHENSON TWEED1E
personally known to me or proved to me on the basis of personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s)whose name(s)is satisfactory evidence to be the individuals)whose name(s)is
(are)subscribed to the within instrument and acknowledged to (are)subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their me that he/she/they executed the same in his/her/their
capacity(ies), and that by his/her/their signature(s) on the capacity(ies), and that by his/her/their signature(s) on the
instrument,the individuai(s),or the person upon behalf of which instrument,the individual(s),or the person upon behalf of which
the individual s)acted, xec • strument. the indiv' acted,e-,;mute• • •• ment.
(signature and office w1Q•lit ll tt �1(nent (signature a •• - •- gag, -•tment)
NOTARY PUB C 5 {PUBLIC,STATE OF NEW YORK $TEP I SP URGB
Nppy sf� of t+>wYORx
Registration No.01SP4906864 ,•:“, No.tl13P4906664
Qualificd in Suffolk County RualIn Suffolk County
Commission Expires Oct.5,2017 ,gElmira Oct.5,2017
TO BE USE ONLY WHEN THE ACKNOWLEDGMENT IS MADE OUTSIDE NEW YORK STATE
State(or District of Columbia,Territory,or Foreign Country)of ss:
On the day of in the year before me,the undersigned,personally appeared
personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s)whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),and
that by his/her/their signature(s)on the instrument,the individual(s),or the person upon behalf of which the individual(s)acted,
executed the instrument,and that such individual made such appearance before the undersigned in the
in
(insert the City or other political subdivision) (and insert the State or Country or other place the acknowledgment was taken)
(signature and office of individual taking acknowledgment)
BARGAIN AND SALE DEED DISTRICT 1000
OC
WITH COVENANT AGAINST GRANTOR'S ACTS B01
BLLOCKK 01.0000
Title No. LOT 011.005
COUNTY OR TOWN
MARK STEPHENSON TWEEDIE Individually and as STREET ADDRESS
Trustee
TO Recorded at Request of
GENTLEMAN'S RIDGE,LLC COMMONWEALTH LAND TITLE INSURANCE COMPANY
RETURN BY MAIL TO:
STANDARD FORM OF NEW YORK BOARD OF TITLE UNDERWRITERS
Distributed by PATRICIA C.MOORE,ESQ.
51020 Main Road
V - Commonwealth Southold,NY 11971
A DAAMIGA COMPANY
COMMONWEALTH LAND TITLE INSURANCE COMPANY
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Title No. ADA-02894-S
SCHEDULE A DESCRIPTION
ALL those certain plots,pieces or parcels of land with the buildings and improvements
thereon erected,situate,lying and being at Orient,Town of Southold,County of Suffolk and State of
New York,known and designated as Plots W and portions of Private Roads as shown on Subdivision
Map,"Survey of the Cedars",Filed in the Office of the Clerk of Suffolk County on July 11, 1906 as
File No.421,more particularly bounded and described as follows:
BEGINNING at a point on the northeasterly side of Old Main Road,where said northeasterly
• side of Old Main Road is intersected by the southerly line of Plot W,as shown on Subdivision
Map,"Survey of the Cedars",said point being situate the following three(3)courses and
distances from the intersection of the northeasterly side of Old Main Road and the northerly
side of Main Road(NYS Rte.25):
I. North 55 deg.30 mm.00 sec.West 166.98 feet,
2. North 23 deg.00 min.00 sec.West 66.00 feet,
• 3. North 46 deg.30 min.00 sec.West 287.83 feet;
RUNNING thence from said point of beginning North 46 deg.30 min.00 sec.West partially
along the northeasterly side of Old Main Road and along land now or formerly Ron A.Melamud
38134 feet to the mean high water mark of the Long Island Sound;
RUNNING thence along the mean high water mark of the Long Island Sound the following
three(3)tie line courses and distances:
1. North 40 deg.32 min. 17 sec.East 132.65 feet,
2. North 39 deg. 14 min.29 sec.East 182.66 feet,
3. North 39 deg.21 min. 11 sec.East 134.06 feet to Plot E,as shown on Subdivision Map,
"Survey of the Cedars";
RUNNING thence along Plot E,as shown on Subdivision Map,"Survey of the Cedars"the
following two(2)courses and distances:
1. South 53 deg.03 min.36 sec.East 312.03 feet,
2. North 39 deg. 18 min.04 sec.East 50.00 feet to Plot X,as shown on Subdivision Map,
"Survey of the Cedars";
RUNNING thence South 59 deg.54 min.56 sec.East along Plot X,as shown on Subdivision
Map,"Survey of the Cedars"148.44 feet to a point;
Tide No.ADA-02894-S
Page-2-
RUNNING thence South 31 deg.30 min. 12 sec.West through a portion of a private road as
shown on Subdivision Map,"Survey of the Cedars"75.00 feet to a point on the westerly side of a
private road as shown on Subdivision Map"Survey of the Cedars";
RUNNING thence along said private road and crossing the terminus of another private road
the following five(5)courses and distances:
•
1. On the arc of a curve to the right having a radius of 76.27 feet for a distance of 32.66 feet,
2. On the arc of a curve to the left having a radius of 116.00 feet for a distance of 81.72 feet,
3. On the arc of a curve to the right having a radius of 90.00 feet for a distance of 35.00 feet,
4. On the arc of a curve to the right having a radius of 30.00 feet for a distance of 57.47 feet,
5. On the arc of a curve to the right having a radius of 755.00 feet for a distance of 131.93
feet to another private road,as shown on Subdivision Map,"Survey of the Cedars";
RUNNING thence along said private road the following five(5)courses and distances:
1. On the arc of a curve to the right having a radius of 47.07 feet for a distance of 46.08 feet,
2. On the arc of a curve to the right having a radius of 78.00 feet for a distance of 43.18 feet,
3. On the arc of a curve to the right having a radius of 168.00 feet for a distance of 85.19
feet,
4. On the arc of a curve to the right having a radius of 60.00 feet for a distance of 37.30
feet,
5. On the arc of a curve to the right having a radius of 232.00 feet for a distance of 46.77
feet to a point;
RUNNING thence North 58 deg.54 min.22 sec.West through said private road 20.13 feet to
the side of said private road;
RUNNING thence along said private road the following five(5)courses and distances:
1. On the arc of a curve to the left having a radius of 122,82 feet for a distance of 54.48 feet,
2. On the arc of a curve to the left having a radius of 63.00 feet for a distance of 27.95 feet,
3. On the arc of a curve to the left having a radius of 170.00 feet for a distance of 48.83 feet,
4. On the arc of a curve to the left having a radius of 272.32 feet for a distance of 75.47 feet,
5. On the arc of a curve to the right having a radius of 34.28 feet for a distance of 45.94 feet
to the heretofore mentioned private road;
Title No.ADA-02894-S
Page-3-
RUNNING thence along said private road the following three(3)courses and distances:
1. On the arc of a curve to the left having a radius of 161.84 feet for a distance of 120.56
feet,
2. On the arc of a curve to the left having a radius of 460.00 feet for a distance of 100.00
feet,
3. On the arc of a curve to the right having a radius of 225.00 feet for a distance of 37.85
feet to northeasterly side of Old Main Road and the point or place of BEGINNING.
CONTAINING an area of 5.0060 Acres.
SUBJECT TO AND TOGETHER WITH the rights of way over certain private roads,as
shown on Subdivision Map,"Survey of the Cedars".
SUBJECT TO AND TOGETHER WITH the rights of way over certain private roads,as open
and travelled within the bounds of Subdivision Map,"Survey of the Cedars".
SUBJECT TO a non-exclusive right of way 10 feet in width from the southeasterly line of
land now or formerly Louis L.Edson over an existing travelled road 120.00 feet more or less to a
private road,as shown on Subdivision Map,"Survey of the Cedars",thence along said private road
southeasterly to the Main Road. The centerline of the 10.foot in width right of way being more
particularly bounded and described as follows:
BEGINNING at a point on the division line between Plot X and Plot W,as shown on
Subdivision Map,"Survey of the Cedars",being situate South 59 deg.54 min.36 sec.East as
measured along said division line 11.00 feet from the southerly line of Plot E,as shown on
Subdivision Map,"Survey of the Cedars";
RUNNING thence from said point of beginning South 02 deg.46 min.56 sec.East over an
existing travelled road 120.00 feet more or less to the centerline of the aforementioned private road.
SUBJECT TO an exclusive easement five feet in width to install and maintain a well and
pipeline for the benefit of land now or formerly Ron A.Melamud,the centerline of which being more
particularly bounded and described as follows:
BEGINNING at a point at the southeasterly corner of land now formerly Ron A.Melamud;
RUNNING thence from said point of beginning through Plot W,a private road,Plot G,and
again said private road,as shown on Subdivision Map,"Survey of the Cedars"the following three(3)
courses and distances:
Title No.ADA-02894-S
Page-4-
1. South 86 deg. 32 min.00 sec.East 75.00 feet, •
2. North 86 deg.42 min.00 sec.East 105.63 feet,
3. North 64 deg.28 min.00 sec.East 126.56 feet.
SUBJECT TO a non-exclusive easement as described in Liber 7535 CP 360 over a portion of
Plot W,as shown on Subdivision Map,"Survey of the Cedars"and being 100.00 feet in width and
approximately 381 feet in length,more particularly bounded and described as follows:
BEGINNING at a point marking the southwesterly corner of Plot W,as shown on Subdivision
Map,"Survey of the Cedars";
RUNNING thence from said point of beginning North 46 deg.30 min.00 sec.West along Old
Main Road and along land now or formerly Ron A.Melamud 381.34 feet to the mean high water
mark of Long Island Sound;
RUNNING thence along the mean high water mark of Long Island Sound the tie line course
and distance North 40 deg.32 min. 17 sec.East 100.13 feet to a point;
RUNNING thence South 46 deg.30 min.00 sec.East through Plot W,as shown on
Subdivision, "Survey of the Cedars"365.98 feet to the northwesterly side of a private road,as shown
on Subdivision Map,"Survey of the Cedars";
RUNNING thence along the northwesterly side of the private road,as shown on Subdivision
Map, "Survey of the Cedars"the following two(2)courses and distances:
1. On the arc of a curve to the left having a radius of 460.00 feet for a distance of 64.33 feet,
2. On the arc of a curve to the right having a radius of 225.00 feet for a distance of 37.85
feet to the point or place of Beginning.
SUBJECT TO a non-exclusive pedestrian easement as described in Liber 12786 CP 380,more
particularly bounded and described as follows:
BEGINNING at a point on the northerly side of a private road,as shown on Subdivision Map,
"Survey of the Cedars",said point being situate the following six(6)courses and distances from the
intersection of the northeasterly side of Old Main Road and the northerly side of Main Road(NYS •
Rte.25):
Title No.ADA-02894-S
•
Page-5-
1. North 55 deg.30 min.00 sec.West 166.98 feet as measured along Old Main Road,
2. North 23 deg.00 min.00 sec.West 66.00 feet as measured along Old Main Road,
3. North 46 deg,30 min.00 sec.West 287.83 feet as measured along Old Main Road,
4. On the arc of a curve to the left having a radius of 225.00 feet for a distance of 37.85 feet
as measured along the northerly side of a private road,as shown on Subdivision Map,
"Survey of the Cedars",
5. On the arc of a curve to the right having a radius of 460.00 feet for a distance of 100.00
feet as measured along the northerly side of a private road,as shown on Subdivision
Map,"Survey of the Cedars",
6. On the arc of a curve to the right having a radius of 161.84 feet for a distance of 90.52
feet as measured along the northerly side of a private road,as shown on Subdivision
Map, "Survey of the Cedars";
RUNNING thence from said point of beginning through Plot W,as shown on Subdivision
Map,"Survey of the Cedars"the following eight(8)courses and distances:
1. North 27 deg.59 min.29 sec.West 51.58 feet,
2. North 03 deg.29 min.48 sec.East 28.30 feet,
3. North 10 deg.01 min.40 sec.West 90.93 feet. •
4. North 20 deg.25 min.59 sec.West 47.24 feet, •
5. North 34 deg.29 min.04 sec.West 61,75 feet,
6. North 47 deg.51 min.42 sec.West 44.75 feet,
7. South 36 deg.43 min.48 sec.West 40.00 feet,
8. North 53 deg.30 min.40 sec.West 112.47 feet to the mean high water mark of Long
Island Sound;
RUNNING thence along the mean high water mark of Long Island Sound the following two
(2)tie line courses and distances:
I. North 39 deg. 14 min.29 sec.East 20.59 feet,
2. North 39 deg.21 min. 11 sec.East 89.70 feet to a point;
RUNNING thence through Plot W,as shown on Subdivision Map,"Survey of the Cedars"the
following eight(8)courses and distances:
1. South 53 deg.30 nun.40 sec.East 107.46 feet,
2. South 36 deg.43 min.48 sec.West 40.87 feet,
3. South 47 deg.51 min.42 sec.East 50.46 feet,
Title No.ADA-02894-S
Page-6-
4. South 34 deg,29 min.04 sec.East 68.97 feet,
5. South 20 deg.25 min.59 sec.East 53.67 feet,
6. South 10 deg.01 min.40 sec.East 97.21 feet,
7. South 03 deg.29 min.48 sec.West 23.40 feet,
8. South 27 deg.59 min.29 sec.East 51.03 feet to the northerly side of a private road,as
shown on Subdivision Map,"Survey of the Cedars";
RUNNING thence on the arc of a curve to the left having a radius of 161.84 feet along the
northerly side of a private road,as shown on Subdivision Map,"Survey of the Cedars"for a distance
of 30.04 feet to the point or place of BEGINNING.
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INSTRUCTIONS(RP-5217-P0F-INS):www.orps.sfate.ny.us
FOR COUNTY USE ONLY I� (� �j New York State Department Of
C1.SIMS Code I-TI�7.3 I6,Q(�1 I i Taxation and Finance
C2.Date Dead Recorded I I, a J / ii) I Office of Real Property Tax Sarvlces
a °n Ye~
C3,Book RP-5217-PDF
1 r ,3 ICI C4.Page J , ,t`! I Real Property Transfer Report(8/10)
PROPERTY INFORMATTON I
T LocationPnaperry 825 Stephenson's Road
•STREET MYER •STREET NYE
Southold Orient
.pn,OR TOWN VILLAGE11957
•SPCODE
2.Buyer Gentleman's Ridge, LLC
Name
•LAST RUIPJCOIVAMr FRET MME
'AST MYE1WIEAM Marg G
3.Ta: Indicate whew future Tax Baa ere to be sent
Bddng t other than buyer address(at bottom of form) ',uncommon:owe FIRST MAME
STREET MAIERArONYE CITY CO TOWN STATE zo CODE
4.Ind
ate thels nu er r ofed Assessmentn the deed 1 sof Assets OR 0 Pan eta Parcel (Only If Part of a Parcel)Check as they apply:
Rol4A.Planning Board with Subdhrision Authority Exists
5.Deed x OR .70 ❑
Property ,FllerrrrEEr Gem _4•AOaB 4B.Subdivision Approval was Required 10,Transfer
Size
4C.Parcel Approved for SuhdiKsion with Map Provided ❑
ISeller
Mark Stephenson TuwUtc(ua.11si and as
•LAST r unConmANr FRETIMAs J
Name
LAST NAIEASST NIr
ATRW TALE ilea s—�prr-
7.Select the description which most accurately describes the Check the boxes below as they apply:
use of the property at the thou of sale: e.Ownership Type is Condominium 0
A.One Family Residential a New Corotmctlon on a Vacant Land 0
10A.Property Located within en Agricultural District
0
10B.Buyer received a disclosure notice indicating that the properly is in an ❑
Agricultural District
!SALE INFORMATION' 15.Check one or mom of these conditions as applicable to transfer.
A.• Sale Between Relatives or Farmer Relatives
11.Sale Contract Date 04/09/2015 B.Safe between Related Companies or Partners in Business.
C.One of the Buyers is also a Seller
•12.Dab of SalelTransfer 09/15/2015 I_ D.• Buyer or Saler Is Government Agency of Lending Institution
_E.Deed Type not Warranty or Bargain and Sale(Specify Below)
F.Sale of Fractional or Less than Fee Interest(Specify Below)
•12.Full Sale Price 2,000,00 0.00 G.Significant Change In Property Between Taxable Status and Sale Dates
(FIA Sale Price is the total amount pad for the property maedblg personal property. _ H.Sale of Business Is Included M Sale Price
I.This payment may be len the form of cash,other property or goods.or to assumption df _ J Other Unusual Factors Affecting Sale Price(Specify Below)
mortgages or other obligatons.)Please round to IM nearest whole dollar moult _ J.None
Comment(s)on Condition:
14.Indicate the value of personal 0 .00
property included In the sale
!ASSESSMENT INFORMATION-Data should reflect the latest Final Assessment Roll and Tax Bill'
15.Year of Assessment Roil from which Information taken(YY) 14 •17.Total Assessed Value 18,400
•15.Property Class 210 _ •15.School District Nome Oysterponds
—
•20.Tax Map Identlfhr(ayRoll IdeMifbrts)(If more then four.attach sheet with additional Identther(s))
1000-017.00-01.00-011.005
CERTIFICATION I
I Certify that all of the Items of information entered on this form are true and correct(to the best of my knowledge and belief)and I understand that the making of any willful
false statement of matarlal fact herein subject me to thrucmcfigionL0f.thILMMILIMe.relative to the making and Sling of false instruments.
SELLER SIONATU13E BUYER CONTACT INFORMATION
/1'—' r't (Enver efanslxln for Ser Buys.Nolo:N buyer Is LLC,eadary,mso®Yon,oxporderL tote Sloth tpnpany,Erato Cr
14(2 �l/l L(Ntn /�s 1 awry owl is noon nevem aeon r Moray.art a'imam!atseoofed bsmroern d an mcividunVrwpom8lo
/� party woo can mower auraern regardrg esu banger not re mores Type or print dewy)
SELLERsxaa DATE
BUYS 1510MTUBE
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f.'�'+11.1 II lit I 1�4 5y E'1 'f ?III j Moore Patricia
•EP CODE
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