HomeMy WebLinkAbout200702270267
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Return Address:
Robert Zauper
P. O. Box 4187
Bremerton, W A 98312
PACIFIC NW TITLE
Deed Ree Fee: $ 34.00
02/27/2007 10:10 AM .
Karen Flynn, Kitsap Co Aud.tor
\ 111111111111111\ 1\1\ 111111 1m 1111111 lltill 1111 lIlt Itllllllllllllll~111I1
Document Title(s) (for transactions contained therein):
1, Statutory Warranty Deed
2,
3,
4.
Reference Number(s) of Documents assigned or releas
(on page of documents(s))
Grantor(s)
1. City of Bremerton
2.
3,
4.
Additional Names on
Grantee(s)
1. Zauper, Robert
2.
3.
4.
of document.
ot, bJock, plat or section, township, range)
a e 2 of document.
ax Parcel/Account Number
Ii Au . 0 IRecorder will rely on information provided on the form. The staff will not read
th cument to verify the accuracy or completeness of the indexing information provided
her n
;::;.7:-:=-'
.
r
AFTER RECORDING MAIL TO:
Rober1 zallper
PIJOIt Office BOJ: 4187
Bl'eJtlerttJP, WA 98312
KITSAP COUNTY TREASURER EXCISE
02/27/2007
Filed lOr Rccord Ilt R.eque5t of:
PAcllle: Nortbwest Title:
E~TOW Number: 31/152105
Tille Order Number J210S71l7
212107EX01290
Tot.al : $10.00
Clark's InH.l
Statutory Warranty Deed
Grantur: City of Brcmerton
GrlUltttl Rllben Zlluper
Abbr~_ed Legal;
Ptll Lots 10..12, Blk 5, Terrell's Addu to Charleston
AlhJitioll~ legaI(N} 00 page: 2
A..~r's Tax PatI:d NlIlllbe J: 3806-Ul~10-0007
Nowy Public in and forth", Stale of W..sbio~n
Rcsidil18llt :-BV'€mer~ A. W A.
MyappolnLmeotexpin:s:-3~~'" - 01
I'OS. J on
I.PH.10
PACIFIC NW TITLE 212112170227121267
Deed Reo Fee: $ 34.00
02/27/2007 10:\0 RM Page:
Karen Flynn, Kitsap Co Auditor
11111111111 mil I11111111 lllllllllll 111111 11111111 11111 11111111II III 11IIII1III
2 of 3
..
EXHIBIT A
All thlll portion of the hereinarter de.5cribed Parcel" A" lying Easterly of a line described as
follo'lvs:
DCllinnioe at a point opposite Hi:hway Engineer's Station (hereinafter referred to as lIES)
9~9.11 on SR 304 line survey ofSR 304, SR 31ntelochange to Montgomery Avenue and l7
feet Easterly tberefrOIll. thence Northerly pllrallel with said SR 304 line survey to a point
opposite lIES 103+00 and the end of this description.
Plln:el"A":
PRCIFIC NW TITLE 200702270267
Oeed Reo Fee: $ 34.00 Pa9a: 3 of 3
02(27/2007 10:10 AM .
~ifl~fI\\ il\\Iflilllllal \\\i ti~11 \Ullil'~ \itl [fIllmlllill I'll' \,~ 111\
..
REAL ESTATE PURCHASE AND SALE AGREEMENT
WITH EARNEST MONEY PROVISION
This agreement controls the terms of the sale of real property.
(Please read carefully before signim?:.)
This Agreement is entered between the CITY OF BREMERTON, a Washington municipal
corporation ("Seller"), and Robert Zauper, a single man ("Buyer"), for the sale and purchase of real
property as follows:
1. PROPERTY. The property, including all improvements and appurtenances situated
thereon, which Buyer agrees to buy and Seller agrees to sell, is commonly known to be located at
124 North Callow Avenue, Bremerton, Washington (the "Property"), and which Property is legally
described in Exhibit A, attached hereto and incorporated herein by this reference. The Property is
further identified in Exhibit B, incorporated herein by this reference.
2. EARNEST MONEY. Received from Buyer, One Thousand and Noll 00 Dollars
($1,000.00) as earnest money and part payment on the purchase price for the Property.
3. PURCHASE PRICE. The total purchase price for the Property is Forty One
Thousand Six Hundred and No/100 Dollars ($41,600.00), including earnest money, payable on
closing.
4. CONTINGENCIES. This agreement is contingent upon:
(a) Acceptance of its terms by the Bremerton City Council.
(b) Buyers review and approval of the title report on the property prior to
Closing.
(c) Financing Contingency. Buyer securing financing as necessary to close the
sale contemplated herein.
Should any of these contingencies not be met prior to closing, then this Agreement
shall terminate except neither Buyer nor Seller shall have any further rights, duties or obligations
hereunder, except that the Earnest Money held in escrow shall be immediately returned to Buyer.
5. CONVEYANCE AND CONDITION OF TITLE. The title to the real property
shall be conveyed by Seller to Buyer at closing by Statutory Warranty Deed, free and clear of all
liens, encumbrances or defects except those described in Paragraph 6 below.
REAL ESTATE PURCHASE AND SALE AGREEMENT
Page 1 of5
6. TITLE INSURANCE. At Closing, Seller shall cause Pacific Northwest Title
Company, whose address and telephone number is 9927 Mickelberry Road NW, Silverdale, W A
98383; 360-692-4141, to issue a standard form owner's policy of title insurance to Buyer in an
amount equal to the total purchase price of the Property. The cost of this policy shall be paid from
Seller's funds at Closing. If an extended coverage owner's policy is requested by Buyer, then Buyer
shall pay the increased costs associated with that policy including the excess premium over that
charged for a standard coverage policy, and the cost of any survey required by the title insurer. For
purposes of this Agreement, the following shall not be deemed encumbrances or defects: rights
reserved and federal patents or state deeds; building or use restrictions consistent with current
zoning, and utility and road easements of record. If title cannot be made so insurable prior to the
Closing date called for herein, unless, Buyer elects to waive such defects or encumbrances, this
agreement shall terminate.
7. CLOSING COSTS AND PRO-RATIONS. The cost of escrow shall be shared
equally between Buyer and Seller, except those fees which are expressly limited by Federal
Regulation. Seller shall pay for excise tax and revenue stamps as applicable. Taxes for the current
year, rents, interest, Association, Condominium and/or Homeowner's fees, water and other utility
charges, if any, shall be pro-rated as of date of closing unless otherwise agreed.
8. CLOSING OF THE SALE. With the understanding that time is of the essencefor
this agreement, this sale shall be closed by ---.Ma~ I, '?oo7 which shall also be the
termination date of this agreement unless said closing date is extended in writing by mutual
agreement of the parties. When notified, the Buyer and Seller will deposit, without delay, in escrow
with Pacific Northwest Title Company all instruments and monies required to complete the
transaction in accordance with this agreement. Closing, for the purpose ofthis agreement, is defined
as the date that all documents are executed and the sale proceeds are available for disbursement to
the Seller.
9. CASUAL TY LOSS. If prior to closing, improvements on said premises shall be
destroyed or materially damaged by fire or other casualty, this agreement, at option of the Buyer,
shall become null and void.
10. POSSESSION. Buyer shall be entitled to possession on closing.
11. SELLER'S REPRESENTATIONS. Seller represents that:
(a) Seller will maintain the property in present or better condition until time of
agreed possession,
(b) Seller has no knowledge or notice from any governmental agency of any
violation oflaws relating to the subject property, and
(c) the property is not encumbered by any leases.
REAL ESTATE PURCHASE AND SALE AGREEMENT
Page 2 of 5
12. SELLER'S ENVIRONMENTAL REPRESENTATIONS. Seller makes no
representations as to the environmental condition of the property. This provision shall survive
closing.
13. HOLD HARMLESS. As partial consideration for the purchase of the Property,
Buyer purchases the property and improvements "as is" and agrees to hold harmless the Seller from
any and all damages, claims, losses, liabilities, judgments, demands, fees, obligations, assessments,
and expenses and costs, which may be imposed upon or incurred by Buyer, or asserted against Buyer
by any other party or parties (including, without limitation, a governmental entity), arising out of or
in connection with any environmental condition existing as of and/or prior to the closing date
whether known or unknown. This provision shall survive closing.
14. DEFAULT AND ATTORNEY'S FEES.
(a) Buyer's Default. If Buyer defaults hereunder, Seller's sole remedy shall be
limited to damages against Buyer in the liquidated amount ofthe earnest money previously paid the
Buyer. Buyer and Seller intend that said amount constitutes liquidated damages so as to avoid other
costs and expenses to either party in connection with potential litigation on account of Buyers'
default. Buyer and Seller believe said amount to be a fair estimate of actual damages.
(b) Seller's Default. If Seller defaults hereunder, Buyer shall have all the rights
and remedies available at law or in equity.
(c) Attorney's Fees and Costs. In the event oflitigation to enforce any of the
terms or provisions herein, each party shall pay all its own costs and attorney's fees.
15. NOTICE TO BUYER. This form contains provisions for an agreement for the
purchase and sale of real estate. The Seller makes no warranty or representation of any kind that
this form, or any of its provisions, is intended to meet the factual and legal requirements of a
particular transaction, or that it accurately reflects that laws of the State of Washington at the time
you enter the agreement. This agreement has significant legal and financial consequences. By
signing this agreement, Buyer acknowledges that Buyer has or has had the opportunity to consult
with an attorney regarding Buyers rights and obligations in this agreement.
16. BROKERS FEES/COMMISSIONS. Buyer agrees to indemnify, defend and hold
harmless Seller with respect to any claim by any person or entity claiming through Buyer to be
entitled to a commission with respect to the transaction contemplated by this agreement.
17. NON-MERGER. The terms, conditions, and provisions of this Agreement shall not
be deemed merged into the deed, and shall survive the Closing and continue in full force and effect.
REAL EST A TE PURCHASE AND SALE AGREEMENT
Page 3 of5
18. NOTICES. All notices required or permitted to be given hereunder shall be in
writing and shall be sent U.S. certified mail, return receipt requested, or by facsimile transmission
addressed as set forth below:
(a) All notices to be given to Seller shall be addressed as follows:
Mayor
City of Bremerton
345 6th Street, Suite 600
Bremerton, Washington 98337-1873
(b) All notices to be given to Buyer shall be addressed as follows:
Robert Zauper
PO Box 4187
Bremerton, W A 98312
Either party hereto may, by written notice to the other, designate such other address
for the giving of notices as being necessary. All notices shall be deemed given on the day such
notice is personally served, or on the date of the facsimile transmission, or on the third day following
the day such notice is mailed in accordance with this paragraph.
19. ENTIRE AGREEMENT. This agreement, including all incorporated exhibits,
constitutes the full understanding between seller and buyer. There have been no verbal or other
agreements that modify this agreement.
20. BINDING EFFECT AND SURVIVAL. This Agreement shall be binding upon
parties hereto and their respective heirs, successors and assigns; and the terms, conditions and
provisions of this Agreement shall survive the closing of this transaction.
21. DATE OF MUTUAL ACCEPTANCE. For the purposes of this Agreement, the
date of mutual acceptance of this Agreement shall be the last date on which the parties to this
Agreement have executed this Agreement as indicated below.
REAL EST ATE PURCHASE AND SALE AGREEMENT
Page 4 of5
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date set
forth below.
SELLER:
BUYER:
THE CITY OF BRE
By: ~
Cary Bozeman, Mayor
ROBERTZAUPER
~~
Dated: I a - ;;;0- 0 &:>
Dated: ;t.1 ]) c c. :LO 0 "
APPROVED AS TO FORM:
R:\Legal\Legal\Files\Current Active Files\Card Shop Real Esate Sale\REPSA-Zauper.doc
REAL EST A TE PURCHASE AND SALE AGREEMENT
Page 5 of 5
'\.Ilsap LOlllllY l\SSessor's J ax UescnptlOIl
Page I of I
Tax Descriptioll
Tax Account No.
13806-005-010-0007
Process No.
111467265
Situs Address
11124 N CALLO'V AVE
t~~.x<~Jl~~~":m.~~"~'~~~;~~~~FI'.C~,l1.JJ_YlJlt..~t~::.w-ilr:::rJlt,1.;~~,::''1c::.~.Jl~~t.~a::<,"~~~~.<c1:~v:.S:U\I\::P,;\~~r.J~~Ai~ZI~!;.::~l:~
TERRELL'S ADDN ,
THE SOUTH 6 FEET OF LOT 10, ALL OF LOT 11, AND THE NORTH G FEET OF LOT 12,
BLOCK 5, TERREL.,s ADDITION TO CHARLESTON, AS PER PLAT RECORDED IN
VOLUME 2 OF PLATS, PAGE 37, RECORDS OF KI1'SAP COUNTY,
\VASHINGTON.>>>EXCEPTTHAT PORTiON RETAINED BY THE STATE OF
\VASHINGTON FOR SR304 UNDER AUDITOR'S FILE NO. 200608180387, kECORDS OF
KI1'SAP COUNTY, \V ASI-HNGTON.
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EXHIBIT A
http://kcwppub2.co.kitsap.wa.us/pls/ilisw/onlineJis jn fo_pkg. tax_ clesc?pj Il_JP_acctjcl... 12/ J 9/2006
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Kitsap County Parcel Search
Legend
Parcels
Road tlarnes
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3806-005-010-0007
COPYright @ Kitsap County 2006
DISCLAIMER: This map is intended for display purposes only and is not intended for
any legal representations.
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EXHIBJT B
http://kcwppub3.co.kitsap.\Va.us/website/parcelsearch/presentation/chamcleonIPRINT .AS... 12/1 9/2006
02/28/2007 15:17
3E,05925559
PAG ~IW TITLF
PAl;E 02/04
,
A L:.S. D!!PART),lEl'o:T Or HoeSJX'G A:-iD VltBA"< DE\'!!L(lP~lENT
SETTLEMENT STATEMENT
B. TyrE OF
I. U rn.4 2. U FHMA
4, n VA ~. n COl'\'.I:\S.
6. FILE NUMBER: 7. LOAN :-',J.\ffiER
31052205
R. MOR,TOAGE lXS. CASE 1>0.'
~ OMB No. 2502-0265
LOA. \i
3. 0 CO:-;V. l';'-lIXS.
C, NOTE: Thill form is fi,mi5h~d t" give: yoU t\ McmCTl't of actultl .ct\.lemmt r;o81.a. Amm.lnb paid to nnd by lho :Jctt.lemcmt ltgent 1'lr~ sho\\'n. rtem~
mEU'kcd" .0.":." WC'J't: aid outAidc tJ1C c1ooing; thev Me !Ihown here for jnfomurtional purposes and i\rC not ;nchJdcd in the totl\ls.
Rob<;rt Zauper
Po.t Office Box 41 87, Bremerton, WA 98312
City ofl3remerton
345 . 6th Slr~t, Suite #600. Brcmerton, \VA 98337
D. l'\A!-.lE & ADDRESS
01' BORRO\VER:
E. NAME & ADDRESS
OF SELLER:
F. KAME & ADDRESS
OF tENDER:
Cr. PROPERTY LOCATION: J24 N Callow Avenue, Bremerton, WA 98312
H. SETTLEMENT AGEl'IT: Pacitic Northwest Title
PlACE OF SETTI.EMEl';'T: 9927 MickclbcxI'Y Road NW, Post Offie<: Box 3607, Silv<::rdele, WA 98383 (.~60) 692-4141
I SEmElvfENT DATE' 2/27/2007 Final
,J. Sllmmarv of &rrow.r'.I Trnn~octjo1\ J(, Summar\' of Seller'3 Tran3action
100. Gro.. Amount Due From Borrower' 400. Groos Amount.Due To Seller:
101 Contract MfC21 price I 401. Con1t,ct ",Ie' price 4] 600.00
102. 1'0Tll0naJ propc:tty I 402, Po...onaf prop<rty
103. Scttlcmont ohnrg.. to bene",..-: (lin.1400) I 403,
104, 404.
JOl. 4O~.
,
i
Ad'mtment. For Item. Paid Bv Sener In Ad~-ancc: Adlu.ltments For .Ttem. Paid B ' Sener In Advantc:
J 06. City/town tmccll \Q 406. Cityllown ta"". to
107, Ccuotytoxcs \0 407. Ccwrty ta""" to
1 08. iU...Mnents to 408. Aa.."".mc:nts to
109, 409.
110. 410.
111. 411.
112. 412.
113, 41l
114, 414.
lIS, 41~,
116. 416.
120. Gross Amount Due From Borrower: 420. Grou Amount Due To Seller: 41,600,00
~^" , n.. ~~ TM ~^^
'201. DCDORtt ar CElTTlCBt mODe)' SOL BGo" dopo.it Is.. instruotiom)
'202. Principal RlOount ofn"", lonnls) 502. Sc:ttlcmcnt ohnrS"IO ,.Uer (lin. (400) 808.21
203. T;:xiJdin.lollll{,) tal<<:n subjc<llo SOl Exillting 1""'(8) W:en llIIbject to
204. 504. l'ayotl' 1 st Mtg. Ln,
205. 50S. l'ayoff'2nd Mlg. Ln.
, 206. S06.
207. 507.
208. ~08,
209. 509.
Ad.illsltnenh For Items Unpaid By Seller: Adju3tmenb For Item. Unpaid By SelIcr;
210. Cill'~o\'" ll1"e, 1<> ~ J 0, CitylloWll fa"", to
211. Comity In"" to ~ I 1. County tt... 10 I
2 J 2. A.!o$e"mt~nt<: to ~ 12. f\~"~~merrt... t"
213- ~13.
214. 514.
215. 515.
216, 516.
217. 517.
i 218. 518,
219. .\19.
! I
220, Total Paid B)'IFor 520. Total Reductions 808.21
, Borrower: rn Amount Due Seller:
IiM r..~ ';^^ <"....--.. ~...-
: 30'. c;ffo~"l amount dUl: from bOrItJWCT (lin, 120) 601. ('''0", nrnoum due 10 ,.1Ier (Iilte 410) 4 I 600,00
~ 302. Lc," omount paid by"'fcr borrowCf (Iin.120) I 602. t"", ,cduclio.. in amount duo ,.11<< (Ii"" $20) 808.21
I - OrO) Borroner: I 1i03. Cash /XIrO) ,UFROM) S.ller; .10,791.79
3ftJ. C..h (UFROM) 000
rm'il..m., r....tilhm 1.~ Oh'\olctt;
form Nfl, 1 ~Rt
3.'86
x
X
Page I ur )
X
X
SB.4.3~38.000.1
HUD-I (3-86)
RESPA, HB 430S.2
02/28/2007 15:17
360E,925569
PAC I'IW TITLF
PAGE 03/04
/
,j
L SETTLEMENT CHARGES Escrow: 31052205
700. T o(a! SalcslBrokers Corrunission: Paid From Paid From
BO,qed On Price $ 1m %" Borrowerl, Seller'.
Di\~,;nn A" Fnlln..... Fund. Funds
701 .~ In AI At
702 ~ Settlement S~ttlcment
to
1m rnmm'. . settlement
704.
onn , 1~ 'm.L r
~01 , r." %
80', Lonn Discount %
80'1, Amra' sat fee to:
...8114. Credit rcoort (0:
805.1 ender', insoection fee
~o~ ~o
807 "<e."mnt;on fee
808.
809,
810
81 L
812,
813.
814.
815.
816,
Qnn nom. . ..-
90 I, Interegt from to <Q\~ ldav 10 davsl
oO? : n1'l"m;l1m Tnr mn III
903. HIl7..ard insurance premium for ~TS. to
904. Flood iml1.lrance ~. , fM \11'8 to
OO.S
906.
1000 1 ~,,"~p,
]001 J-Ia.a." ,no".a.", $ o 00 ner mnnth
1 002 \fort.a~e inourance o months ~ $ o 00 llef month
1003 Cit\' OfOoertv taxes o month. ill~ 0.00 nM' month
1004, en"nt, n~n.rtv taxes o on.,..,. mnnth
100 S Annual assessments nM -"
1006. F100djnsurance o months '"~ 0,00 no:r month
1007. o months fa! ~ o 00 ocr mnnth
1008. A__re_ate Ad'ustment
1009.
1100
1101, closinp : Title 352.9!
1102, Escrow Fee: $650.00 Sales Tax: ~'5 00
J 103. Title examination to
1104 Title insumnce hinder tn
1105
1106 1>.In'..." feos In
11 07. Attorney's fees to
(includes above item Numbers; )
1108, Title insurance to l'acifi.c Northwest Title
(includes above item Numbers: ) 445,26
1109. lender's coverage S
!l10. Own.<"envem.e $41.600.00 Premium: ~410.00 Tax; $35.26
1111
1112,
1113
J II.~
11nn
120 1. Jl,ecording fees: Deed $ 0.00 'Mo>1..oo ~ 0.00 :ReJ eases $ 000
1202. Citv/colU1tv taxlstanws: Deed S 0.00 :Mortl!age $ 0.00
120'1 State tax/Stamo", need $ 0,00 - . ODD
1204. Excise Tn" to I('ltsao COillltv Treasurer 1000
1205.
nnn A "d;';n>.a] ~.
) 301 SUITe" to
1 '102 p..t ;.".....I;M In
1303
1304.
1305,
1306.
) ]07
130R
1 ]Oq
1310
1311,
1112
B]l
lunn Tntal" I"'J."~_ fP. 0" Un.. I n ~ ,~"ori~ 1 _ ~,,1 _ lin. 1m S.rlinn Iil ~n~ ?1
Form No, 1582
Page 2 of3
SB.4.353S.000.!
x
x
x
x
02/28/2007 15:17
3585925559
F'AC I'll,) TITLF
F'AI;;E 8,1/04
SELLER'S AND/OR BORROWER'S STATEMENT
Escrow: 31052205
huve carefully reviewed the HUD-l Settlement Statement and to the best of my knowledge and belief, it is a true ll1\d accumt. statcnlent of all receipts lll\d
Jisbur!'ements m~de on my account or by me in this trnnsac.tjon. I further certify that I have received a COP)' of the HU])..1 Settlement SUltemenl.
8urr('lwerslPurchtlset"S
SeUers
City of Bn:merton
By:
. Cary Bozeman. Authori7.ed Signer
The HUD- I Settlement Statement Which I have prepared is a true and accurn(e ~ceount o[this transaction. I have caused or will CHuse the fimds to be
disbunled in accordance with this lltlltement.
SettlemeJ!i( gent ~ ~~ D~te: c2 -;; 7 -0 7
, Cindy L. Rose. Pacific ofthwest TItle
W ARNI : It is a crime to knov.ingly make tlll"e statements to the United States on this or any other similar form. Penalties upon conVlctJOn cen include a
f1n~ or imprisorunenl. For details see: Title 18 U.S, Code Section 1001 and Section 1010,
SELLER'S TAX INFORMATION
SJn,LER'S CERTIFICATION OF TAXPA VER IDENTIFlCATION NUMBER (~uhstitutc W-9)
You are required by law to provide the Settlement Agent (see block H) with your correct taxpayer identification number. If you do not provide your SettlernCl
~cnt with your com:ct to.xpayer identification number, you may be subject to civil or criminal penalties impo~ed by law in the Tax Refonn Act of 1986,
under Internal Revenue Code Sections 6045(e), 6676. 6722, 6723 and 7203.
Under penalties ofperjuf)', 1 certify that the ntunber shown on this ~tutement is my correct taxpayer idCl1tilieationnumber,
TIN 91-600]231
Signed;
City of Bremcrton
TIN
Signed:
TIN
Signed:
TIN
Signed:
Sellers Forwarding Address:
345 - 6th Street, Suite #600
Bremerton
WA 98337
PROCEEDS FROM REAL ESTATE TRANSACTIONS (substitute fonn t099-8)
TIle information contained below ll1\d in blocks E, G, H Md r is importAnt tax information nnd is being supplied to thc Internal Revenue Service. If you are
required to file a return. a negligence penalty or other sanction v.ill be imposed on you if this item is required to be reported and the IRS determines that it
11M not been reported. lfthis real e(lUlte was your principal residC1lee, file Form 2] 19, Sale or Exchange of Principal Residence. for any gain, \\ith your
income tax re(l1m; for other transactions, complete the applicable parts of Form 4707, Form 6252 lIndlor Schedule D (Form 1040),
GROSS PROCEEDS:
1;
41.600.00
o Check here jfthe Seller received or \\~Il receive prnperty or services a< part of Ute consideration.
Real property tax amount, reimbursed $ 0.00
PROCEEDS AUOCATION FOR MULTIPLE SELLERS
When more than one seller is illvolved in the transfer of property, they may elect to allocate the GroS" Proceeds between the name<l parties for the purpo.. of
reporting such mt~U"ts to dIe Intcrn~l Revenue Service. Thi" DOES NOT apply to a hnsband-\\1fe relationship or to a partoership, If the proeccd.q are
allocated, the sum of the indi\'idual allocations must equal tilC total Gr<>s. Proceeds Above, Use the space below or submit ~ .<heet listing name, address,
taxl'Hycr identification number, and allocation amount.
PAge 3 oD