Loading...
HomeMy WebLinkAboutHenry Buller and Washington Mutual Bank Augusta Richmond GA DOCUMENT NAME: ~ l!:' IV (? '1 'i) \) L-U:.R. II^' a LUA$" \ I\l ~ 1fl~ )'Ylll1i ~.4L BANR. DOCUMENT TYPE: A 0j Q~ f. ff) eoJ T YEAR: :;<'D (j ~ BOX NUMBER: 1 (p FILE NUMBER: IlP 3' Lf NUMBER OF PAGES: LI SUBORDINATION AGREEMENT This SUBORD~ION AGREEMENT (the "Agreement"), made and entered into this ~i:jv day of 6 Clo, , 2002, by and between Henry Buller, , ("Borrower"), Washington Mutual Bank, FA ("Washington Mutual"), and the subordinating party, Housing and Neighborhood Development Department, (the "Creditor"), WITNESSETH: WHEREAS, Creditor is holder of a mortgage on property located at 2921 Shelby Drive, (the "Premises") from Borrower to Creditor in the amount of $18,405 dated 02/14/2002,recorded 02/25/2002 and recorded in Volume 776, Page1368, in Richmond County Records, (the "Subordinated Mortgage"); and Modification Agreement recorded OS/22/2002 and recorded in Volume 790 Page 1425 in Richmond County Records. WHEREAS, a new mortgage has now been or will be executed by the Borrower whereby Washington Mutual is holder of a mortgage on the Premises from Borrower to Washington Mutual dated , in the principal amount not to exceed $37,000 (the "New Mortgage") WHEREAS, Creditor intends by this Agreement to waive the priority of the lien on the Subordinated Mortgage in favor of the New Mortgage; NOW THEREFORE, in consideration of the sum of One Dollar cash in hand paid to the Creditor, the receipt of which is hereby acknowledged, the Creditor expressly: (I) waives the priority ofthe Subordinated Mortgage and (II) subordinates all rights, titles, or interest under the Subordinated Mortgage to the lien ofthe New Mortgage to the same extent as if the New Mortgage had been executed and recorded before the execution and recording of the Subordinated Mortgage. IN WITNESS WHEREOF, the said has caused its corporate seal to be hereto affixed and these presents to be signed in its name and behalf by of , this day of , 2002. ~ ~-Ltfu.6h, 6'.e-:;, i ~__ "',.. leA JI f:) f if<.. / ..;- lt~s, .-de.~~ ~Dr4~ By: Mfjrt , "By: ,2002 Dated County of11t..1ftrl0/'(j) }SS: ~fore me the undersigned, a Notary PUblic~nd said County and State on this & tf-(,; day of lt5T' ' 2002, personally appeared ~ ft[JU ff~ , to me known to be the identical person who subscribed the name ofthe maker ther of to the foregoing instrument as its ~~dJL.. President and acknowledged to me that 'f:Je- executed the same as his free and vol ntaryact and deed and as the free and voluntary act and deed of such corporation, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year last above written. My Commission expires NaIIry ~ Alchmond oeUi'llYl ~ElQrg!iI My 00mmIIeI0n Eaplree Jon, ~I MS' J~~~~ Service Link, agent for American Pioneer Title Insurance Company Commitment No:645814 - 1 Schedule A 1. Commitment Effective Date: 06/03/2002 2. Policy (or Policies) to be issued: (a) Owner's Policy (AL TA Owners Policy (10/17/92)) (b) Loan Policy (AL T A Loan Policy (10/17/92)) Proposed Insured: Washington Mutual Bank, FA, its successors and/or assigns as their interest may appear Amount $0.00 $36,000.00 3. Fee Simple interest in the land described in this Commitment is owned, at the Commitment Date, by: Vincent Hollander and Henry Buller, as Joint Tenants with Right of Survivorship 4. The land referred to in this Commitment is described as follows: See Exhibit A attached hereto and made a part hereof Tax 10: 109-1-085-00-0 Service Link, agent for American Pioneer Title Insurance Company Alia Commitment Schedule A (10/17/82) Valid only if Schedule B and Cover are allached 645814 - 1 .r ~,~":';9:i" ,: ,', "'."1'" :~ "I"'~:r;'::~I}. J" ~'''.Y' .:~~'~:~;,:'-- Service Link, agent for American Pioneer Tille Insurance Company Commitment No: 645814 - 1 Schedule B - Section I Requirements 1. Documents satisfactory to Service Link, creating the estate or interest to be insured must be executed and duly filed for record. 2. Payment to or for the account of the grantors or mortgagors of the full consideration for the estate or interest, mortgage or lien to be issued. 3. Furnish proof of payment of all bills for labor and material furnished or to be furnished in connection with improvements erected or to be erected. 4. Service Link requires the payment of all taxes and assessments and any penalties and interest, due and payable at closing. 5. Properly drafted and executed owner's affidavit from Vincent Hollander and Henry Buller. 6. Service Link must be notified of all parties being added to title, prior to the loan closing. A judgment search must be completed for any parties being added to tille. Service Link reserves the right to add additional requirements and/or exceptions as may be deemed necessary, upon review of the judgment search. 7. Record instruments conveying or encumbering the estate or interest to be insured, briefly described: Properly drafted and executed Security Deed from Vincent Hollander and Henry Buller, to Washington Mutual Bank, FA, securing a lien in the amount of $36,000.00. ANY DEED PREPARED IN CONNECTION WITH THIS TRANSACTION MUST INCLUDE THE RELATIONSHIP OF GRANTOR AND GRANTEE IN ORDER TO DETERMINE THE APPLICABILITY OF TRANSFER TAXES, IF ANY. 8. If Vincent Hollander is deceased or will not be signing the new mortgage/deed of trust, please call Service Link prior to closing of the new loan. Title may be re-searched and additional requirements and/or exceptions may be added to the Commitment to insure, as may be deemed necessary. 9. Payoff of Security Deed Dated 06/11/1997, Recorded 06/19/1997 in the office of the Recorder of Richmond County, Georgia, in Book 561 Page 3, executed by Vincent Hollander and Henry Buller to First Choice Mortgage, Inc., which states that it secured a debt in the principal sum of $29,850.00. Assigned to Homeside Lending, Inc. as set forth in Book 584 Page 2288, recorded 2/9/98, Richmond County Records. 10. Payoff of Security Deed Dated 02114/2002, Recorded 02/25/2002 in the office of the Recorder of Richmond County, Georgia, in Book 776 Page 1368, executed by Vincent Hollander and Henry Buller to Housing & Neighborhood Development Department, which states that it secured a debt in the principal sum of $18,405.00. Modification Agreement as set forth in Book 790 Page 1425, recorded 5/22102, Richmond County Records. ..-.-.--'- ..--...----' Alia Commitment Schedule B - Section I (10/6/82) 645814 - 1 ,'- '!::;l';,' . " "..: \ ~. I . "T " : .~. : r '.,' ~ --'f'{1/;'~."".!I~., ~ . ~'. ,~i,:~ ; . ~'~ '~.. 'IF:,'" Service Link, agent for American Pioneer Title Insurance Company Commitment No: 645814 - 1 Schedule B - Section II Exceptions Schedule B of the policy or policies to be issued will contain exceptions to the following matters unless the same are disposed of to the satisfaction of the company: 1. Defects, liens, encumbrances, adverse claims or other matters, if any, created, first appearing in the public records or attaching subsequent to the effective date hereof but prior to the date the proposed insured acquires for value of record the estate or interest or mortgage thereon covered by this report. 2. Any taxes or assessments, not yet due or payable. 3. Any discrepancies, conflicts, or shortages in area or boundary lines, or any encroachments or any overlapping improvements or other boundary or location disputes (can be eliminated or amended in mortgagee's policy upon proper evidence being furnished). 4. Rights or claims of parties in possession, and not of record in the public records, or right to a lien, for services, labor or material heretofore or hereafter furnished. NOTE: Upon receipt of a satisfactory Affidavit of Agreement this exception will be deleted. 5. Restrictive covenants affecting the property described in Schedule A. 6. Any roadway or easement, similar or dissimilar, on or under, over or across said property, or any part thereof and not of record in said records. 7. Any title or rights asserted by anyone, including but not limited to persons, corporations, governments, or other entities, to tidelands, or land comprising the shores or bottoms or navigable rivers, lakes, bays, ocean or gulf, or lands beyond the line of the harbor or bulkhead lines as established or changed by the United States government or riparian rights, if any. 8. 2001 County Taxes are Paid in the amount of $28.11. Taxes accruing in the current year. Tax 10 109-1-085-00-0. NOTE: CONTACT LOCAL TAX AUTHORITIES FOR EXACT AMOUNTS DUE, PRIOR TO LOAN CLOSING. 9. Subject to Security Deed Dated 06/11/1997, Recorded 06/19/1997 in the office of the Recorder of Richmond County, Georgia, in Book 561 Page 3, executed by Vincent Hollander and Henry Buller to First Choice Mortgage, Inc., which states that it secured a debt in the principal sum of $29,850.00. Assigned to Homeside Lending, Inc. as set forth in Book 584 Page 2288, recorded 2/9/98, Richmond County Records. 10. Subject to Security Deed Dated 02/14/2002, Recorded 02/25/2002 in the office of the Recorder of Richmond County, Georgia, in Book 776 Page 1368, executed by Vincent Hollander and Henry Buller to Housing & Neighborhood Development Department, which states that it secured a debt in the principal sum of $18,405.00. Modification Agreement as set forth in Book 790 Page 1425, recorded 5/22/02, Richmond County Records. Alia Commilmenl Schedule 8 - Section II (10/6/82) 645814 - 1 ''''''It:;::?;;.::.. . .., ~ . . '~,' .' . . .: <. ~,~f'~~~~:: t. "T;~~~; ~:~~'. Service Link, agent for American Pioneer Title Insurance Company Commitment No: 645814 - 1 Schedule B - Section II Exceptions 11. The laws of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence. Alta Commitment Schedule B - Section II (10/6/82) 645814 - 1 ,. '~/fY -.-'" '~;1~' . '."' '", . ~. ~' . ~ '.;\ I . of :)~~ "," T, Exhibit "A" Legal Description All that certain parcel of land situated in the 123rd District G.M. of the County of Richmond, State of Georgia, being known and designated as being located on the West side of Shelby Drive in a certain subdivision known as Richmond Hills and being more particularly shown and designated as Lot 20, Block 0 upon a certain plat of said subdivision made by C. Eugene Towell, Registered Professional Engineer, recorded in the Office of the Clerk of the Superior Court of Richmond County, Georgia, in Realty Book 19 N, at Page 232, and specific reference is hereby made to said plat for a more complete and accurate description as to metes, bounds, and location of said property. Tax 10: 109-1-085-00-0 645814 - 1 f.' ~...p> 'ri.f.~1~~:\:<: ":' '~.... -'.-"'m~B" "[ .; .:. _31. I 11(., t:. .;. . I, .,f~~. \1' . ~~!:~. I. .,: Exhibit "A" Legal Description All that certain parcel of land situated in the 123rd District G.M. of the County of Richmond, State of Georgia, being known and designated as being located on the West side of Shelby Drive in a certain subdivision known as Richmond Hills and being more particularly shown and designated as Lot 20, Block D upon a certain plat of said subdivision made by C. Eugene Towell, Registered Professional Engineer. recorded in the Office of the Clerk of the Superior Court of Richmond County, Georgia, in Realty Book 19 N, at Page 232, and specific reference is hereby made to said plat for a more complete and accurate description as to metes, bounds, and location of said property. Tax 10: 109-1-085-00-0 645814 - 1 ':, 'J'~4:;>' ~. "f' "7)1,: ';~:~~r " i: '. . ~~: .::;.:~:f SUMMARY OF YOUR INFORMATION This is a summary of the morlgage loan information you recently gave us. Please carefully review the summarized information below. !fyou find any discrepancy with the information that you gave us originally, please make the required corrections below, If you have any questions, please call us at (888) 444-4404 to speak with your loan consultant. Please be sure to sign the last Ilage of this summary and return the original in the envelope provided. Mortgage Applied For: Product Type: FIXED (X ) Tenn: CONV 360 YOURNEW MoIttGACELOAN TERMSJ" , .' ' " ,,"'" -. l Lender Case Number: 4991388 Loan Amount: $36,000.00 Interest Rale: 7.000% Points: 2.349% Subject Property Address Street City AUGUSTA State Type of Home: SINGLE FAMILY D Purpose of Loan: Monthly Homeowner Association Fees: Purchase Price: Cash Deposit on ConlracLlSales Agreement: Desired Closing/Settlement Date: JULY 4, 2002 If this is a rclinance loan Amount of Existing Liens: $ 3 2 , 215 . 81 Amount of Cash-Out to be received at Closing: $906.80 .. ". ;:;~1. .ABOUrr"'THE.:'iIOME:,: . '" . . ".. '....-' "d' - I ".-,', _'1;'" '-.1' . .',,'.',. '. .' ~: ' 2921 SHELBY DRIVE . ~:' f .-....1...,:". ,,' GA County RICHMOND Home Use: PRIM Unit Number [If Condo] Zip 30906 Down Payment Amount: Closing Costs Paid By Seller/Other Credits: Estimated Market Value: '::,'~qY.:R:'I~9}:':<:, ..' Co-Borrower Generation: (Jr, Sr, etc) First: Middle: . ':,:,'" Bon'ower First: Middle: Last: HENRY BULLER Social Security Number 471-26-8874 Citizenship: U. S. CITI ZEN Day Phone (inc!. Area Code) Last: Generation: (Jr, Sr, etc) Age Social Security Number Age Fux Number (ine!. Area Code) Evening Phone (inc!. Area Code) (706) 560-1389 Email Address Citizenship: Day Phone (inc!. Area Code) Evening Phone (inc!. Area Code) Fax Number (inc!. Area Code) Email Address ( ) Married (X ) Unmarried (includes single, divorced, widowed) ( ) Separated ) Married ) Unmarried (includes single, divorced, widowed) ) Separated Present Address Street Address: 2921 SHELBY DR, City: AUGUSTA State: GA Zip: 30906 (X ) Own ( ) Rent _No. Yrs. Will occupy subject property as primary residence: (X ) Yes ( ) No Present Address Street Address: City: State: Zip: ( ) Own ( ) Rent _ No, Yrs, Will occupy subject property as primary residence: ( ) Yes ( ) No . . . ..' ;~~". . ,:' l I :);.'::',:.;.." ~::~(~~r';:;' ~~,\:jt':;:;:i:':'~~;;,f:~:]J;'~:':J'~:~PVi~~XgJjg~:lN.~gM~I~"::;f~~J,c;~;~:~:i:!~~~~;!~!;'::;:!::i~;::;~;: ~~::;~i~~,::~~J~~~t;ji,!~;<::i~1::~:~t\)i;.('~:!;t' :<i ,: ~:'.! .' . IMPORTANT NOTICE: AlimollY, cllild slIpport, alld separate mailltellallce illcome IIeed IIot be revealed if Borrower or Co-Borrower does II0t clloose to IIave slIcll illcome cOllSidered as a basu'for repayillg tile loan Borrower Co-Borrower Self Employed: ( ) Yes ( X ) No Self Employed: ( ) Yes ( ) No SOCIAL SECURITY $411. 00 (Monthly) (Monthly) SOCIAL SECURITY $154.00 Totul MonUlly Income $565.00 Total MonUlly Income Borrower CHECKING/SAVINGS ...., ."':::':<;ABOUT-YO,(JR:iASSETS',. "., . .,,1 .... """""1";' 0" .'.,.1',.....", - ' " Co-Borrower ,'.':' ': ",,; II,", $374.00 Total Assets $374.00 Total Assets .'J". 'AR' OU' T"Y'O.' U' R"'RE'A"L' ':E' 'STA"T' 'E' 'L'lAB"IL:'I'T'" IE" 'Si'<"':;:':'~'. ",r~:.,'; ,', I':' . ,,". -.'. .'.... .". j:...... . . . , '," .....:;f- I- ',.' . '-,' _," . .,'. -'" "I"' ,'. ..;~~,.', ", ~;..~~ The credit histories of all borrowers contain the following real estate loans (i,e" first mortgages, second mortgages and equity lines of credit): Uability # Date Opened 1 08/01/1997 Monthly Payment* $274.00 Current Balance $28,670.00 Subject Property YES Primary Residence YES Property Status' RETAINED Paid aUor prior 10 closing YES Online Documcnts, Inc. Page 1 of 2 L5t930PP 0110 LOAN # I 4991388 . . .., .:' , . . .." OTHEk ~IABILI'iTES : . .'. .' III additioll to your real estate liabilities. the followillg other types of liabilities (credit cards. installment loans, etc) exist: HIe B1 Bl * Name SOUTHTRST BC CITIFINANCIA Accuunt # 4606001007139031 6071056212192054 Monthly Payment Amount $24.00 $99.00 Unpaid Balance $1,175.00 $3,333.00 Borrower Alimony/Child SupportlScparate Maintenance Co-Borrower Alimony/Child SupportlSeparate Maintenance (Monthly) (Monthly) (KEY: B=Borrower, C=Co-Borrower, *=/iabilities which will be satisfied upon sale of real estate oWlled or upon refinancing of the subject property) '. ".j, ,:" 1'i.,>.::i.'i;'!;':':'::;;':'!At::*NOWLEDGEME~'T:rA:ND ~GREEME~T". By signing below, I acknowledge and agree to 'the foliow{~g: " ,',,,,,", . . . . ' (l) I am applying for the loan described above, to be secured by a first mortgage or deed of trust on the property described above. I represent that the property will not be used for any illegal or restricted purpose. (2) All information 1 have provided above is truc, correct, and complete to the best of my knowledge, does not contain or omit any material information, and is providcd for thc purpose of obtaining the loan describcd abovc. (3) I agrce to change and supplement the information I have provided above if any such information changes before the loan closing. (4) I agree that the lender may verify all information above from any source named above, check my credit, employment and other rcferences, obtain credit reports about me from credit reporting agencies, and answer questions about lender's crcdit experience with me. I also agree that the lender may ask me for additional information supplementing the information above, before deciding whether I qualify for any loan. (5) Lender will retain the original or a copy of this application whether or not it is approved and whether or not my loan closes. , ,> Bo~.."cr's s;gnatur~ . jh~, & ~ffL-/ HENRY LLER . ,,' ., . .,~, , 0' '''r.' . . , " . . '.. I . . ..' . . .'.OPTIONAL:GOVERNMEN'TSURVEYi:'.":" .:1': ",.' ~ . " '. : ." ;.. .' . > '_,' ,.'~ '.. h ",It IC', ";;::'~'/. '. .' I. t .... .. l,",; (.;, ,,,,- " : ' .,", '.' -',.', 'I,' . . , . The Federal Governmen/ requests that you provide information /0 moni/orour compliance with equal credit oppor/unity,fair housing and home mar/gage disclosure laws. You are not requiredtofurnish this information, but are encouraged to do so. These laws prohibit usfrom discriminating on the basis of this information, or on whether you choose to provide it. if you do not wish to provide this information, please check the applicable box below. Date: Co-Borrower's Signature Date: ~fA/1\ t /~ ()~~ 1/ BORROWER: () I do not wish to furnish this infonnation Race/National Origin: D American Indian, Alaskan Native D Asian, Pacific Islander D Other (specify): Sex: D Female [J[J Male D Hispanic D Black CiJ White CO-BORROWER: ( ) I do not wish to furnish this infornlation Race/National Origin: D American Indian, Alaskan Native D Asian, Pacific Islander D Other (specify): Sex: D Female D Male D Hispanic D Black D White Online Documents, Inc. Page 2 of 2 L51930PP JUN-24-2002 13:02 A. Settlement Stateinent SERVICE LINK 888 761 5951 P.02/03 U.S, DapartmentofHouslng' ~STIMATED ~. T\iftA ofL"""" f\ua lJ... -~..... -~~ I. OfHA 2. OFmHA 3. Dconv. UnIns. 6. File Nlllllbcr 1 7. Loan Number I 8. MortplO rns~ ~ Number .. nvA ~. I.... 14-01 C. NDte: !Nt IOIllI ;~f."=' iInll Dyllle ~ c= lIIloWn. ~~~~.o.o. ~~lIlI~"~~J:.~~~; InllllllDlBIe. w IHG: II . em. to 1IlIlke.... to. UNllld QI'\ ... I<lIm. - ....... D. NAME OF BORROWER: HENRY BULLER ')0')1 AUGII~T A ~ClQM E. NAME OF SBL.LBR.: REFINANCE F. NAME OF LijNOE.R.: WuldngtOD Mutual 8--- - "I rati. 1a Fl 322Cj6 G. PROPERTY ADDRESS: 2921 SHELBY DRIVE, AUGl.1STA, 30906 H. SETIUlMENT AGBNT: Service Link -. r .,.,...... -' CW"" U - OF r : III IN' K Yur- I ~R')oo; I ill. N: ..nn ~~...-- Al\l\ -- , ... ...... -~. . -~, .n1 dn1 "^"" Ml? - .... ._, ., IlnA 1'1. ..".. 11\& .n. 1M ."" I for ItAMlI ~. 1llQ dna .1^ ..1" 111 4" .."" 41,} 1'" -~--- ~.o;n8.1'l. ,t"n -- , ...... nil!: TO C'C:' I c:0. 200. ...~, .._- 'VIn 1111I AU"" 'NT I'lI.JIO TO ~~Lt J:R "". I'\.. NIt 2n' -. ll;'OOO ,00 .,'" _.... , ...."n' ""., - 'In "". ~ o:tI.t ')tII; """ !:IlIA l\lIR "JtI'1 1:n'7 ~ CI'lIl ?M 11II0 ......--- ?2 "'" ')... AU ..." ,a.o: .,.11 '1111 .,.., a... ?fll J;.A ...a !l1Cl ??n Tf\TAI DAln ::ll.nnn nn 11'0 TI"I'1'AI ' nus: QF=11 s:g 'Uln ... A (:1.1 - -- J;M /"!Al:1-I AT ~1=TIl ~. . , C:I 'Oft. - . , .""', 2 0:08.11 ani ~...... - -. .-. 'U\., 'U:: nnn nn All, I .. V1~ t"'6.Cllool 33.Ul.U M~ - _..~~ n no TitlcExpJaJ Soulmncnt SyJIaD PrtntId lW241Z002 1112:36 REV. HUD-J (3186) JUN-24-2002 13:03 SERVICE LINK u.s DEPARTMsm' OF HOUSING AND URBAN l)~Vcl.Ut'M~N 1 888 761 5951 P.03/03 J ,." "......."""'.,... .......... -. ~F:T1l.- cUI:NT S D...n~' --- .- rL PAID FROM PAID FROM 7M TnTA' ~AI I.......... CD 0.000 _ BORROWER'S SEl.LER'S .. FUNDS AT FUNDS AT 7no 4: ... SETTlEMENT SE~MENT 7n' II In "m" ROO nAIIl llIl. 'ft_ . . iii/. uS.ao lIII7 I ftD~ nl..........n' ot.lII&.11binaton u an.. """ " II:n 8M .... ...hofnntOD Mul:uAl Am': u_ ~ ....w Jl JII\1 cu.a1 rll.o.c.) 2115.00 BUYer Ml7 .... "'........, 715.00 .."" '" TIllITS 2.'1.00 lU\Q In Mutual 380 00 8.0 . ~.... In .. Mo......' 45.00 811 '" rica. 1"1004 B 75 ann m;M~ R~OUII;!I:;n J:lV I ..... CltI. 'n........ tr- IA ....lII M.v 1'\.....,. 1M.S6 llO2 .... tA ~. "'A7.....l '"~_A_ a...MJ,_ "'r ... ClII.4 QIl" 1000 ' wlT\.l I ",...nco !:nA 'M. HA7.....'A~._A ,,~ ....lII I~n 78.68 100' "'^ All C I"", 111M ' 'L "'^ .""l Imn 25.'72 1004 11 __ All II I....... 25.'14 1005. - "'^ Il9I II Imn onno .. MW u......". 16 . "" 11M Tm ,'.... ... . LiDk US.OO 11111 1107 In LiDJr. 180.00 1''''' OOIU 11ft'! . t08 ........~ "...... .,n7 A--......'....Q ,a_lIIn' I t1nR tn . l. :I.Dk 90,00 \ lino ,f, 3" """ "0 - 110.00 ...n 10.. .112 111~ ... LiBk 1n.nn 1,nn 1m1 30.00 . It.....Q." t. 30.00 .707 "'--' 4l 17m ~t. ,_ '''......nlt.... In AJl. larvie.. L'lnk 108.00 . 7lI!I 1~M ,''''. Q.__u 13117 1'1lY.'\ ..'lo6 ,~l; .~R 1307. 1308 1400, TnTA' c....ot.... I A.... M~ .....'n" I{\ 2.!i08.11 HUO ClERl1FICAl1ON 01' BUYI!R AND llELUiR I haw: card\AlylO'/lllMld lhlI HIJD.1 ~ SIIIMWIIIlId to lIIA IIHl ~~ Ilnd lleIIIr. D IS a 1IUI1llllI.~~ $ll1emM1 D111ilrs:Sbt nI ~ mmIlIlII1 fI')' ~ Of ey me In _1lInudIon.1 ftlIlIW aIlIIylllM I hBvw **'* . t/l11IfDlIhe HlJO.t ~ IIIIIIllO 10 IUlfltr aq_1n tie ~ III emn or Clll\IialolII tIIlI ~ Bnlll'iokl IiInTIc:M US-AeIIIl~ IUCtIlIIlIl'or~. ~~Y IIlJU.iR 12tm4 WARNlNCllIT IS ACRIilE 'I'O~UAKE FALSE EraTO na; UNrrED STATU ON lMl:s OR AN FORM. Pl!JW.1 uPON CONVICTlOH CAN INCl.UD& A F!HI; AND . FClI'DETAI.S TINl1G; U.s. COOIi 6GCTIOH 100t AND SI!CTlON 1010. TtI, HUOol ~1 DIIcl:mcnl.tlkl11 110>1I___ ~ lIlr\1O lI!1d -.,..16 __ of IhIo 1mnsAcllan, '......llWIllll QI' wi gvce tile IIms III DB dllllnM In ICICIOIlIa/Illl -.tlh lhI5 &lBI8mlIn1. -". I""'''''''"~".,,,.,,,,, By, ",a,.. RRV. mID-I (3/86) TOTAL P. 03