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Permit 78 Forrestal Circle South (4) If You Have Any Questions If you have any questions, you may call us at 1- 800 - 772 - 1213, or call your local Social Security office at 904 - 730 -5555. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at: SOCIAL SECURITY SUITE 100 3733 W UNIVERSITY BLVD JACKSONVILLE, FL 32217 If you do call or visit an office, please have this letter with you. It will help us answer your questions. OFFICE MANAGER Aiiii, ./ Lille E --. - 1 stock ,j-- ' 48. " 34''' C' :' n ' 4 44t'' C : - , t I - 0 33 rY1JpaLl'1/40.91/4/ - 1.$2-4t- btf- P TM.0.."., L A ) en:r4 t . -a. Wirtly242) 4 , Vey . ° c- P , ai i_. cctiv-9-'v g_ . ,r , PRov �C� l� G F p,I1_0 \C e4.ACi i CISB UILDING pF • 01* 2 ' '‘(2--t'(3 j 400,-- B.; /".../..teipt. ' ---- V , , .2,, 'N 0` JACKSONVILLE ELECTRIC A THORITY ,, jai 21 WEST CHURCH S — REE T, JACKSONVILLE, FLORIDA 32202 -3139 • (904) 632 -5200 T *gym"•" cr " c nut ::1: ill CYCLE ACCOUNT NUMBER � BILL DATE 1 1 SERVICE ADDRESS � 1 :::, 19 36930- 00078- 0000-3-21 -E 8/28/98 78 FORRESTAL CR S I RATE I II RESIDENTIAL 'IIIlII!' III{ IIIIIII111' Ii11I' I +IIIUIIIIIIlilllllllll'IFIIII I CONSUMPTION HISTORY '� I STEWART ANA C AUG. 1998 544 V 4 78 FORRESTAL CIR S AUG. 1997 1,243 t< -1 \ ATLANTIC BEACH FL 32233 -3326 JULY 1998 852 I, „i J ULY 1997 1,440 t: H A” tillP o A...,.. ' ,43 iii i AVI :.L.. .... . ' .. • L:II� ATE© RtSW ;� . 1 METER NUMBER READ � ' DAYS F URR£'. r REAOINO• "METER "'CONS i MP 1<�N • ' I' . AUIE R EVE!1:1Ra CM .� DATE BILLED F HADU 3 TYPE CONSTANT - CONSUMPTION COST 84959922 8/25 29 87049 REGULAR 1 544 KWH $1.55 HIGH CONSUMPTION KLERT ELECTRIC CHARGE $ 29.58 For the next few months our water GROSS RECEIPTS TAX 1.08 and electric usage could oar due FRANCHISE FEE 1 80 to record temperatures an drought. ATLANTIC BEACH TAX T he reduce our bill, lea §e: Mi an Or replace air conditioning . ters. Set the thermostat at 78 e ee or higher, Have our duct - wotk checked Tor leaks and have the the central air system tuned Run your washing ma hire and d w only when full. Fix leaky toilets anU use low volume fixtures an hoover heads. Water your garden and lawn with care. Call us for a free energy or water ev 1 ation,of your home to obtain information on how to save end water. IT IS OUR PLEASURE TO SERVE YOU 1 . TOTAL DUE `"" NON- TAXABLE FUEL AMOUNT $7.28 q $.01339/KWH BY 9121 T AV IO I ;45.06 PLEASE INDICATE ADDRESS CORRECT /ON BELOW 1.5°% LATE PAYMENT FEE Page 2 Financial Survey - Community Development Block Grant 13. Have you had sewer or septic tank problems? yes X no If yes, which of the problems have you experienced? a. Foul odor Y b. Seepage of septic tank into yard c. Backed up household plumbing XC d. Other ,g,e ve 5"e'k. -6;4, ./, ".... /W® Do the problems increase during periods of heavy-rain fall? yes y no 14. Is there hot running water in the household? yes x- no Is there cold running water in the household? yes X no 15. Do you have a complete kitchen (water, cooking, refrigeration)? yes y no 16. On the chart below, circle your household's family size. Is the total annual income of your household: more than less than the income level shown below for your household size? Family Size - Number Annual Income Level (i $15,650. 2 $17,900. 3 $20,100. 4 $22,350. 5 $24,150. 6 $25,950. 7 $27,700. 8 or more $29,500. 17. Are you on a fixed income (Social Security, SSI, Retirement) yes ,Y' no 18.List income source(s) /AL sfcv4 �Hf 1r) SS 19. Do you : own X rent your home? If you own your home, please present a copy of your warranty deed and a most recent utility bill (water or electric)1 as proof of ownership and residency with this survey.. If you rent your home, please present a copy of your lease with this survey. Signature of Homeowner(s): S e4„4 ss 9- CITY OF r . ,itteut c Fear.( - � �uda ,:. ,• 800 SEMINOLE ROAD ATLANTIC BEACH, FLORIDA 32233 -5445 ? TELEPHONE (904) 247 -5800 FAX (904) 247-5805 '� � '% SUNCOM 852-5800 INCOME VERIFICATION FORM PART 1. To be filled out by Applicant/Employee: Applicant/Employee Name: _aJ R 0, I?1 vE2R Address: rig (OR Ncs 7'f3 L-- C 1 ROLE SoUTiF f % L• acli. FL• 3 as 33 Social Security Number: / ,e3 - Lt 6 - /13A I hereby authorize release of my income information to the City of Atlantic Beach, Florida. Applicant/Employee Signature a c - Date c 1-# - -8.? PART 2. To be filled out by Social Security Administration, HRS or the Employer: S.S. Administration, HRS or Employer: Please complete the following and return the requested information to the Director of Community Development, 800 Seminole Road, Atlantic Beach, Fl., 32233. Applicant/Employee's name: Gross amount of income paid monthly: Employment to be continued? Yes_ No . If no, please explain Employer Signature: Title: Employer Telephone Number: Date: AGENDA ITEM #8C JULY 09, 2001 CHANGE ORDER No. r—�,, C 3 o 7- d ( Date C7-5 -0 ( FINANCIAL SURVEY • COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM CITY OF ATLANTIC BEACH, FLORIDA Date: 9- �— 9? 1. Homeowner(s) Name: NA C , 7") ) 11/EM 2. Address of House: 78 — ORic G: IRCt , Drl ?l , fAI1 N7%G & h ) 3. Telephone Number(s) where you can be reached during the day or early evening: (Home)91 Y_�' //.57 (Work) (Other) — 4. Is person completing survey the Head of Household? y Es 5.Age of Head of Household 4 I l i 6. Is the Head of Household: female x' male A minority ? yes no 7. Number of handicapped living in household / JS A6L Ii) Prise,/. 8. Total number of rooms in household 6 MO I/2 M/i.S AN a 4,AVriso2 y PEA 9. Number of persons living in household (other than Head of Household): Age 0 -5 years Male Female Age 6 -17 years Male Female _ Age 18 -39 years Male Female Age 64 and over Male Female 10.Water supply is from: City )( Well Other (list) 11. Sewer service is by: City X Septic Tank Other 12. Does your toilet flush? Yes X No Nor WELL • iT eta GS of7-t4 CONTRACTOR PAYMENT REQUEST Homeowner: Payment #1 - 33% Complete_______ Address: _ Payment #2 - 33% Complete Atlantic Beach, Florida 32233 Payment #3 - 10096 Complete Contractor: Amount Requested $ Contractor: I hereby request an inspection to receive payment # for the amount of $ certify that I have satisfactorily completed the necessary work to justify this request and that all bills incurred for labor used and materials furnished in making said repairs and improvements have been paid in full to this date. Attached is a description of the work completed and the amount of payment requested by work item. Contractor's Signature: Date: t•aww ** *** ** ****** www.**++«xw axw**++ axaw *wwi*w ****** ** ****Rxww *wwrr rx awwxw w w*wxrww : *ww *r *xwrewxw* Homeowner: I/We hereby agree that the work stated by the contractor has been completed and approve payment to the contractor in accordance with the contract and contingent upon inspection and concurrence by the Rehabilitation Inspector. It is understood that the actual amount disbursed will be based on the fmdings of that inspection. Owner's Signature Date: Rehabilitation Inspector: I hereby certify that I exercised reasonable care to determine that the work performed at the above address meets specifications and was completed in a satisfactory manner however, neither the undersigned nor Jacksonville HUD is in any way responsible for the acts or omissions of the contractor, any subcontractor, or any of the contractor's agents or employees, or any other person performing work under the construction agreement. The contractor has provided a release of all liens, if any, in connection with this contract and has provided the property owner with a copy of each warranty or guarantee due the property owner from the contractor for work performed. Rehab Inspector: Date: Approved. Forward to Finance Department for payment this date. Date Director, Rehabilitation Loan Program 1 PROCEED ORDER DATE , - 7-o TO: Sunstate Enclosures____ This is to authorize you to proceed with work specified in our contract dated for improvement work on the property located at _�— . The amount specified in the Rehabilitation Agreement is $_//, 3/ eV _. Please proceed in accordance with the Contract. You are to commence work no later than O 3- All work shall be completed according to the Work Write -Up, plans, Change Orders, Addenda and Specifications within Sixty (60) calendar days after starting construction. Name(s) of Owner(s) if • ye (Owner's Signature) (Owner's Signature) ADDRESS: r s /( (e la afi_� t3 a lam 33 � �� - r// .44/ (Local Public Agency Representative) Copy: HOMEOWNER- CONTRACTOR AGREEMENT Property Improvements To (Address): 78 Forrestal Circle South Owner (s) Name (s): Ana Rivera -- Legal Description: 1 . HOLD HARMLESS: Contractor shall agree to defend, indemnify, and hold harmless the Owner, City of Atlantic Beach, Florida from liability and claim for damages because of bodily injury, death, property damage, sickness, disease of loss and expense arising from Contractor's performance under this agreement to install or construct home improvements to be paid out of the proceeds of the Owner's rehabilitation loan. Contractor is acting in the capacity of an independent Contractor with respect to the Owner. 2. LIEN WAIVERS: Contractor agrees to protect, defend and indemnify, owner from any claims for unpaid work, labor or materials with respect to Contractor's performance. Final payment shall not be due until the Contractor has delivered to the Owner complete release of all liens for work completed arising out of Contractor's performance, or a receipt in full covering all labor and materials for which a lien could be filed or a bond satisfactory to the Owner indemnifying him against any lien. 3 . SCOPE OF WORK: Contractor acknowledges that he has prepared the Contractor's Proposal (Part II of this Agreement) and that such proposal is accurate and consistent as to the name of the Contractor will undertake, and the price. Contractor acknowledges the performance requirements established in the General Specifications of the Rehabilitation Standard Performance Manual effective June 1, 1982 and warrants that all work undertaken will conform to said specifications. 4 . CONTRACT AMOUNT AND PAYMENT SCHEDULE: The City of Atlantic Beach shall pay the Contractor for the performance of the rehabilitation work, subject to additions and deductions by approved Change Order the contract sum of ($21,312.00) payments will be scheduled as follows, subject to the City and the Owner's acceptance of the work done: Upon completion of 33% of the work, a progress payment of 33% will be made. Upon completion of 33% more of the work, an additional payment of 33% of the contract price will be made. Upon completion of 100% of the work, the remaining funds will be disbursed. 1 of 6 5 , TIME OF COMMENCEMENT AND COMPLETION: Owner shall provide written authorization to Contractor to commence work. Contractor agrees to start work ten (10) calendar days after the receipt of the written Notice to Proceed. If the Contractor fails to commence work within ten (10) days of the Owner's notification to commence, Owner shall have the right to terminate this Agreement. Such notice of termination shall be in writing. The Contractor agrees to complete the work within sixty (60) calendar days after the commencement of work pursuant to the date of the Notice to Proceed. If completion is delayed for reasons beyond Contractor's control, the Contractor shall provide timely notice to the Owner of the reasons for such delay. It shall be the Contractor's obligation to substantiate its claim by adequate documentation. 6. CHANGE ORDERS: Except in an emergency endangering life or property no changes in the work shall be made by the Contractor unless he has received a prior written order signed by the Owner and Authorized by Community Development Director of the City of Atlantic Beach. The contract sum and the contract time may be changed only by a properly executed Change Order. No extra costs will be paid to the Contractor when he has neglected to properly evaluate the extent of the rehabilitation work. Under no circumstances will the contingency fund, if any, be authorized for work other than totally unforeseen circumstances arising after the commencement of the work. 7. TERMINATION OF AGREEMENT: If the Contractor defaults or neglects to carry out the work as specified under the Paragraph "Scope of Work" or fails to perform any provision of the Contractor documents, the Owner may, after fifteen (15) calendar days written notice, terminate this contract and , select a substitute Contractor. If the expenses of finishing the work exceeds the unpaid balance on this contract, the Contractor shall pay the difference to the Owner. If the Owner fails to perform any applicable provisions of the Contract, the Contractor may, after fifteen (15) calendar days, terminate the contract and recover from the Owner payment for all work satisfactorily completed including reasonable profit and damages. 8. WARRANTY: For good and valuable consideration, the Contractor hereby agrees to provide a full one- year warranty to the Owner, which shall extend to subsequent Owners of the property to be rehabilitated. The warranty shall extend to subsequent Owners of the property to be rehabilitated. The warranty shall provide that improvements, hardware and fixtures of whatever kind or nature installed or constructed on said property by the Contractor are of good quality, and free from defects in workmanship or materials or deficiencies subject to the warrant contained in this paragraph. Contractor and Owner agree, however, that the warranty set forth in this paragraph shall apply only to such deficiencies and defects as to which the Owner or subsequent Owners shall have given written notice to the Contractor, at its principal place of business, within one (1) year from the date of Contractors final payment. The Contractor further warrants that failure by the Contractor to respond to valid complaints by the Owner, or subsequent Owners, that causes additional damages to the property are also subject . to the warranty contained in this paragraph. 2 of 6 9. ARBITRATION: If a dispute arises as to the validity of a complaint not satisfied under the warranty clause of this contract, a panel of three (3) independent professionals shall be chosen by the City of Atlantic Beach to arbitrate the dispute. The panelists shall be chosen on a rotating basis. The finding of the panel shall be irrevocably final, conclusive, and binding on the Homeowner and the Contractor. 10. SUB - CONTRACTORS: Contractor agrees that all warranties contained herein shall apply to all work performed under the Contract, including that performed by any sub - contractor. 11. ACKNOWLEDGMENT: The above warranties are in addition to, and not in limitation of, any and all other rights and remedies to which the Owner, or subsequent Owners, may be entitled, at law or in equity, and shall survive the conveyance of title, delivery of possession of the property, or other final settlements make by the Owner and shall be binding on the undersigned notwithstanding any provision to the contrary contained in any instrument heretofore or hereafter executed by the Owner. 12. INTEREST OF CERTAIN FEDERAL OFFICIALS: No member of or delegate to the Congress of the United States, and no Resident Commissioner, shall be admitted to any share or part of this Agreement or to any benefit to arise from the same. 12b. BONUS, COMMISSION, OR FEE: The Borrower will not pay any bonus, commission, or fee for the purpose of obtaining the Government's approval of his application for this loan, or any other approval or concurrence required by the Government or its designee to complete the rehabilitation work financed in whole or in part with this loan. 12c. INTEREST OF PUBLIC BODY PERSONNEL: No member of the governing body of the Public Body who exercises any functions or responsibilities in connection with the administration of the loan and no other officer or employee of the Public Body who exercises such functions or responsibilities, shall have any interest, direct or indirect, in the proceeds of this loan, or in any contract entered into by the Borrower for the performance of work financed in whole or in part with the proceeds of this loan. 12d. INTEREST OF OTHER LOCAL PUBLIC OFFICIALS: No member of the governing body of the locality in which the property to be rehabilitated is situated, and no other public official of the locality who exercises any functions or responsibilities in connection with the administration of the loan shall have any interest, direct or indirect, in the proceeds of this loan, or in any contract entered into by the Borrower for the performance of work financed in whole or in part with the proceeds of this loan. 3 of 6 13. CIVIL RIGHTS: The Grantee agrees to abide by the spirit and intent of the Civil Rights Act of 1964, as amended, and the Civil Rights Act of 1968, as amended, and the anti- discrimination provisions of Chapter 120 of the City Ordinance Code, in that its operation under this contract is free of discrimination against its employees, persons, or groups of persons on the basis or race, color, sex or national origin. 14. EQUAL EMPLOYMENT OPPORTUNITY: The Grantee I agrees to abide by the Equal Employment Opportunity a part thereof. 15. LEAD BASE PAINT HAZARD ACT: The Grantee agrees that no lead based paints or substances containing lead shall be used in any part of this project. Treatment necessary to eliminate immediate hazards shall, as a minimum, consist of the following: a. All surface conditions identified as immediate hazards shall be thoroughly cleaned (washed), sanded, scraped, wire brushed or otherwise cleaned) so as to remove all cracking, scaling, peeling, chipping and loose paint on applicable surfaces. Such surfaces that have been so treated shall then be repainted with two (2) coats of a suitable non - leaded paint. b. Where the paint film integrity of the applicable surface cannot be maintained, the paint shall be completely removed or the surface covered with a suitable material such as gypsum wall board, plywood or plaster, before any repainting is undertaken. Sunstate Enclosures, Inc. _ Ana Rivera Name of Contractor Name (s) of Owner ---- 3-07 - • . � 3. o 1 Signature of Contractor Date Signature of • e Date l/ ' C e ftes riP4 t Title (if officer of Corporation) Signature of Owner Date 3 1 /77 j t/4/ j4 L✓ i i9 9 / 0 78 Forrestal Circle South Address of Contractor Address of Owner (s) A Jiro Witnes 4 by Date Witne Vs by Date 4 of 6 ATTACHMENT I EQUAL EMPLOYMENT OPPORTUNITY CLAUSE FOR CONTRACTS SUBJECT TO EXECUTIVE ORDER 11246 During the performance of this contract, the contractor agrees as follows: 1. The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, religion, sex, or national origin. Such action shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff, or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the contracting officer setting forth the provisions of this nondiscrimination clause. 2. The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex or national origin. 3. The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding, a notice, to be provided by the agency contracting officer, advising the labor union or workers' representative of the contractor's commitments under Section 202 of Executive Order 11246 of September 24, 1965, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. 4. The contractor will comply with all provisions of Executive Order No. 11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor. 5. The contractor will furnish all information and reports required by Executive Order No. 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations and orders. 5 of 6 ATTACHMENT 1 Page -2- 6. In the event of the contractor's noncompliance with the nondiscrimination clauses of this contract or with any of such rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order No. 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order No. 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. 7. The contractor will include the provisions of Paragraph (1) through (7) in every sub - contract or purchase order unless exempted by rules, regulations, or orders of the Secretary of labor issued pursuant to Section 204 of Executive Order No. 11246 of September 24, 1965, so that such provisions will be binding upon each sub- contractor or vendor. The contractor will take such action with respect to any sub - contract or purchase order as the contracting agency may direct as a means of enforcing such provisions including sanctions for noncompliance; provided, however, that in the event the contractor becomes involved in, or is threatened with, litigation with a sub - contractor or vendor as a result of such direction by the contracting agency, the contractor may request the United States to enter into such litigation to protect the interests of the United States. 8. The offerers or bidder's attention is called to the "Equal Opportunity Clause" and the "Standard Federal Equal Employment Opportunity Construction Contract Specifications" set forth herein. 9. The goals and timetables for minority and female participation, expressed in percentage terms for the contractors aggregate work force in each trade on all construction work in the covered area, are as follows: 1. The goals for minority participation are 21.8% for each trade. 2. The goals for female participation are 6.9% for each trade. 6 of 6 General Requirements REPLACE ROOF SHEATHING Replace all rotted or damaged roof sheathing. New sheathing shall match existing sheathing. All work subject to open roof inspection by the Building And Zoning Inspection Division. All work shall conform with the building codes and shall be permitted and inspected accordingly. SF INSTALL MODIFIED BITUMEN ROOFING Install a modified bitumen roofing with FHA approved rubber roofing, base sheet, and metals. Mfr's specs.and local bldg. Codes shall be adhered to. All areas of new flashings shall be sealed and step -roofing nails shall not penetrate underside of sheathing. Color selection of shingles by Owner. Contractor shall give (7) yr. labor warranty and (20) yr. Mfr's warranty in writing to Owner. SF REPLACE RAFTER TAILS Replace all rotted/damaged rafter tails using pressure treated materials. New rafter tails shall match the existing rafter tails. All work shall be done as per standard trade practices. EA REPLACE FASCIA BOARDS Replace all rotted/damaged fascia boards using pressure treated materials. New fascia boards work shall match the existing fascia boards. All work shall be done as per standard trade practices. All joints shalt fit tight and shall be caulked properly after installation. LF REPLACE SOFFIT Replace all rotted/- damaged soffit using exterior grade Plywood and screening for ventilation. Include all required trim. New soffit shall match the existing soffit. All work shall be done as per standing trade practices. SF REPAIR/REPLACE WINDOW(S) Repair /replace the window(s) with a single hung pre - finished aluminum window, including screen. All windows shall be installed, plumbed, leveled, and caulked on the interior- exterior. Window shall fit the opening properly with no excessive gaps. Repair all walls after installing window. Accepted: Pan — American, Croft, Anderson, Pella. EA REPLACE ENTRY DOOR (S)— FRONT Replace the entry door with a solid core Luan door, lockset, weather- stripping, and threshold. Door shall be installed, leveled, and plumbed. All work to be done as per standard trade practices. The face sides and all edges of door shall be sealed. Door shall be weather -fight after installation. EA INSTALL SCREEN DOOR(S) — ALUMINUM — FRONT DOOR Install screen door with prefab aluminum screen door including jamb and all hardware. Screen door shall be installed, plumbed, leveled, and shall fit the opening tight to prevent the access of vermin. Acceptable units 1. Croft, 2. Pan American. EA DINING ROOM REPAIR CEILING Repair the damaged areas of the ceiling as per Standard trade practices. All repairs shall match The existing ceiling finish. AL REPAIR SLIDING GLASS DOOR Repair sliding glass door, ensuring that door closes properly and securely locks. All work shall be done according to standard trade practices and adhering to local ordinances. EA Livingroom REPAIR CEILING Repair the damaged areas of the ceiling as per Standard trade practices. All repairs shall match the existing ceiling finish.. AL REPAIR LIVINGROOM CENTER BEAM-CEILING Repair center beam on the ceiling — jack up center beam. All work shall be done according to standard trade practices and adhering to local ordinances. EA HALL REPLACE/INSTALL TILES — LAUNDRY ROOM Replace/install VCT tiles as per standard trade practices and following all local ordinances. Tile color to be selected by homeowner. SF REPAIR DAMAGED WALL AREAS — LAUNDRY ROOM Repair the damaged wall areas as per standard trade practices. Wall finish shall match existing finish after repairs. SF BEDROOM # 1 INSTALL BASEBOARDS OU�ti''te Install baseboards. New baseboards to match Busting. MI work shall be done as per standard trade practices. LF Total REHABILITATION LOAN PROGRAM RESPONSIBILITIES OF HOMEOWNER AFTER CONTRACT IS SIGNED Until Work Begins Start planning ahead. Plan adequate storage space for the contractor's tools, equipment and materials. Make arrangements for the contractor to get into your property if you will not be home during the day. To avoid mutual confusion, one member of the family should be delegated as the spokesman to discuss problems or questions that may come up. If all household members work or will not be home during the construction, consider designating an agent such as a close friend or neighbor or relative not living with you to supervise the contractor's work. You are responsible to make sure the contractor does the work exactly as he states he would do in your contract. Prepare your property and furnishings for the rehabilitation , use this period to send your drapes to the dry cleaners , wash your curtains. There will probably be dust and dirt from the work , protect your furnishings and clothes , put all breakable and valuable items away so they won't be broken or misplaced. When the Work Begins Keep your copy of the work description handy and refer to it often. Do not ask for work to be done if it is not written in the work description. Check with the City Hall if there is anything you do not understand. Remember you are responsible for ensuring that the contractor does the work correctly as bid. Assistance will be provided if required but the work must be acceptable to you. Try to stay out of the construction area, especially children, this will help prevent injuries and allow the workmen room to work. Try to keep a good relationship between your family and the contractor again, delegate someone to be the spokesman for the family. Stop, problems before they start , if something isn't going the way you feel it should, or if you don't understand it, speak to the contractor at once and get an acceptable explanation or correction before it progresses too far. If the contractor cannot give you an acceptable explanation, stop the work and call the City Hall for assistance. Expect the unexpected , in most cases changes and improvements will be new and exciting to you and will give you much pleasure; however, unforeseen problems may be uncovered during the course of the work which may require a change to the contract. Be prepared if this should happen , discuss changes with the contractor and get a good explanation of the change required and why. Try to visualize what the change will look like. Be flexible. All changes to the contract must be approved by you and the City and must be in writing. Your contractor is responsible for supervision of his workers. If he cannot be present, make sure that he tells you who to talk to if you have a problem or questions. Win cooperation from the workmen with good basic human relations. A word of appreciation , an unexpected pot of coffee or even a pitcher of cold water. Small gestures like these usually produce more efficient and better workmanship. I ast but not least. The work must be acceptable to you and must be done in accordance with the contract documents. Make sure that you know what is being done to your home and that you are getting exactly what the work description states. City of Atlantic Beach - 247 -5817 CONTRACTOR'S AFFIDAVIT STA OF FLORIDA SS COUNTY OF DUVAL BEFORE ME, the undersigned Notary Public, personally appeared _ _, who, being first duly sworn By me, deposes and says: That on , 19 _ _ as owner, and as contractor, entered into a certain construction contract whereby said contractor agreed to provide certain labor and materials for said owner upon the following described lands belonging to said owner, located in the City of County of and State of Florida, to -wit: That deponent is the _ of said corporation, herein referred to as the contractor, and has personally supervised the performance of said contract. That said contract, has been fully and completely performed, and said contractor and all persons, firms and corporations contracting or dealing with, or directly employed by said contractor in connection with said building operation or in connection with said contract, have been paid in full. This affidavit is made in compliance with the provisions of the Uniform Mechanic's Lien Law as approved June 4, 1935, as revised, Laws of Florida, and to enable said contractor to receive his full and final payment from the owner, under the construction contract above referred to. Subscribed and sworn to before me this day of , 19_,___.__. Notary Public, State of Florida at Large, My commission expires: CHANGE ORDER No. Date of Contract _ Date — - -_ _ Owner Name: Property Address: — —__ — ! Contractor Name: __ -- Contractor Address: - Phone Number Description of Work Change: AMOUNT: CATEGORY: (Please Type) SUM Changes and work affected hereby, are subject to all contract stipulations and covenants. This Change Order is made a part of the contract dated first above, parties have hereunto set their signatures. $ _ Contract Price + or - $ -- Change $ ---- ___ -- Total Owner Approval: -- Date: —_ __ Contractor Approval: —_ _ - -__ Date: — Rehab Specialist Approval: Date: - Program Administrator Approval:_ _ Date: — -- Source of Funds: $—__ Contingency Owner Contract Copy: Owner, Contractor, Loan file, Technical file, Financial Institution (If contract price changed) Categories of changes: 1. Hidden damages 2. Time extension 3. Deletions of non - required items or unusual allowances 4. Required items that were missed on initial inspection 5. Equal substitution of material or alternative cure for deficiency at same or lesser price 6. Totally unforeseen circumstances arising after commencement of work 1/1)1 6624P1974 1 wi t_ it •! V. Lr.Jir, v... r NOE & EAKIN -� (a[FIC! -[_ [',IVRY 599 ATLANTIC BOULEVARD, 32233E 6 ATLANTIC BEACH, Z11j 1114, rrantU 1eeb Made the 8 day of December A.D. 19 88 by `t JOHN W. LEWIS and CYNTHIA A. LEWIS , his wife hereinafter called the grantor, to SCOTT R. STEWART and ANA C. STEWART , his wife whose post office address is: 78 Forrestal Circle South, Atlantic Beach, Florida 3223 Located in Duval County, Florida hereinafter called the grantee: red esentativesand assigns of t individuals, and the successors include ccessors an tof parties this instrument and the heirs, legal corporations) itne88etl`: That the grantor, for and in consideration of the sum of $ TEN & NO/ 100nd other valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, r&ieases, conveys and confirms unto the grantee, all that certain land situate in Duval County, Florida, viz: 7., Lot 4, Block 12, ATLANTIC BEACH VILLA, Unit No. 1, according y 7 � to plat thereof recorded in Plat Book 30, Page 56, of the = c co t „ �: - ? p ' 23 Current Public Records of Duval County, Florida. m v -I x; r,-, -a rn = _. r _ :� _• 2: c> v in G) SUBJECT TO covenants, restrictions, easements of record and; t::: r t taxes for the current year. o._ D, o A Subject to that certain mortgage to SHEARSON LEHMAN MORTGAGE N F' CORPORATION, dated February 27, 1987, recorded March 3, 1987, w in Official Records Volume 6288, Page 1235, as re— recorded in Official Records Volume 6300, Page 1098, of the current public records of Duval County, Florida, in the original principal amount of $44,440.00, which sum SCOTT R. STEWART and ANA C. STEWART, his wife, expressly assume and agree to pay, and also I assume and agree to pay all the obligations of JOHN W. LEWIS and CYNTHIA A. LEWIS, his wife, under the terms of said mortgage and the Veterans Administration guarantee. C&grtller with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. • �({�,� � YJO alie in to ola, the same in fee simple forever. �\ /; hereby covenants with said grantee that the grantor is lawfully seized of said land in fee f �n� the grantor ht y i � � simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the sarne against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 19 88 J tt 1itneis 1411 ljereof, the said grantor has signed and sealed these presents the day and year first above written.. Signed, sealed and delivered in our presence: , r J relimr i ar / vvi AO e ek(14N tEW,IP. A _ ii:P:6 '1 kia t S CYNTHIA A. LEWIS _ _ '- � N,c1,1°(. Cy •. �_. 711'` -Lt. STATE OF FLORIDA a'' DOCUMENTARY,, STAMP TAXI > 5 `" DEPT, O F REVENUE :'�.% 'l ___ :..D o _ _ . ; 4 � 2 6 4 ',_ _ � >J� . n . DEC 13 ea � �1= -- " U PA. — / (_ • STATE OF Florida F. 11°29 =' COUNTY OF DUVAL 1 ticn cnv r TiFY that on this day, before me, an officer • 1 000 1 1 �DgDS 0.0 00 QOQ�� CD �tiR1EE� RE. DD amt R cooFbt • Vi}1 f PG J'7 •'� Wilibla i ../. oL, , I nf� NOE & EAKIN UFFI E�FC ' 599 ATLANTIC BOULEVARD, SUITE 6 ATLANTIC BEA 32233 Tilig IN, rruntU Peetb Made the 8 day of December A.D. 19 88 by JOHN W. LEWIS and CYNTHIA A. LEWIS , his wife hereinafter called the grantor, to SCOTT R. STEWART and NA C. ST-EW1 T , his wife / 1i cc C. K'ive ea_ whose post office address is: 78 Forrestal Circle South, Atlantic Beach, Florida 3223 Located in Duval County, Florida hereinafter called the grantee: rep esentatives smi assigns of individuals, and the successors include l t ccessorsandassig assigns of orpo at to instrument end the hilts. legal P ititessetll: That the grantor, for and in consideration of the sum of $ TEN & NO /100nd other valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, releases, conveys and confirms unto the grantee, all that certain land situate in Duval County, Florida, viz: 10 Lot 4, Block 12, ATLANTIC BEACH VILLA, Unit No. 1, according ..1.... to plat thereof recorded in Plat Book 30, Page 56, of the j . ,, - n . nt �a Current Public Records of Duval County, Florida. cam F co _ ; 3 r' c =i SUBJECT TO covenants, restrictions, easements of record and r, _.. 72 6 taxes for the current year. v x'�o > t7 a a S ubject to that certain mortgage to SHEARSON LEHMAN MORTGAGE N F' CORPORATION, dated February 27, 1987, recorded March 3, 1987, t, in Official Records Volume 6288, Page 1.235, as re- recorded in Official Records Volume 6300, Page 1098, of the current public records of Duval County, Florida, in the original principal amount of $44,440.00, which sum SCOTT R. STEWART and ANA C. STEWART, his wife, expressly assume and agree to pay, and also I assume and agree to pay all the obligations of JOHN W. LEWIS and CYNTHIA A. LEWIS, his wife, under the terms of said mortgage and the Veterans Administration guarantee. (loge tiler with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Intie nub to u.[a, the same in fee simple forever. ---..\ i (\ c i1nit the gra ntor hereby with said grantee that the grantor is lawfully seized of said land in fee Y covenants wit granee J simple; that the grantor has good right and lawful authority to sell and convey saki land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 19 88 P in Pitiless i!11 tiered, the said grantor has signed and sealed these presents the day and year first above written.. Signed, sealed and delivered in our presence: / �c. I � ✓j�i' gar j / .. N 7 L�L•tG( Aice6 ( 1 , - CYNTHIA A. LEWIS CB I1 1- 0 0 • A • ,._.1 *T Y --_ . � STATE °F F= L O R 1 DA! a� DOCUMENTARY , ,,ri" STAMP TAX" �` `" DEPT. OF itEVENUE ,,: T ` �`' '{ '4' — PR. 1.4 DEC 13'88 \',1C i- 44. STATE OF Florida = nose' %� {. �r,r rn CIE - --_ -- _ ,,.. MORTGAGE NOTE Atlantic Beach, Horida For value receive the undersigned (jointly and severally, if more than one), promise to pay to the order of the City c Atlantic Beach, a municipal corporation, 800 Seminole Road, Atlantic Beach, Florida 32233, the principal sum c $_21,312.00 , being payable in lawful money of the United States of America at 800 Seminol Road, Atlantic Beach, Florida 32233 or at such other address as the holder from time to time may specify by written notice t the maker. Said principal sum shall bear no interest and shall be reduced in amount at the rate of 1 /10th per year uni reduced to a zero balance at the end of 10 years. Any unforgiven balance shall become immediately due and payable if tl: maker transfers title to or moves from the premises securing this note within the 10 year period. In the event of the death c the maker of this note, this note shall remain in effect and the principal sum reduced at the above rate of 1 /10th per year only a member of the makers immediate family takes up residence in the subject home, under any other circumstances the not shall become immediately due and payable. This note is to be construed and enforced according to the laws of the State of Florida, and is secured mortgage on real estate of even date herewith. If default be made in the payment of any of said sums or in the performance of any agreements contained herein, then at the option of the holder of the same, the principal sum then remaining unpaid shall immediately become due and collectible without notice, time being of the essence of this contract, and said principal sum shall bear interest at the highest rate allowed by applicable law, from such time until paid. Each maker and endorser waives presentment, protest, notice of protest and notice of dishonor and agrees to pay all costs, including a reasonable attorney's fee, whether suit be brought or not, if counsel shall after maturity of this note o default hereunder or under said mortgage, be employed to collect this note or to protect the security thereof. G ALL- 0 411 $2 ciiik‘e. Name of Maker u . /.-, (seal) Signature f Maker Date: 3- 1- 01 Maker's Address: qg � 4 s 9 te..„,_re„:„ he..-c, v. 2 a ;.3 3 STATE OF FLORIDA DOCUMENTARY STAMPS IN THE AMOUNT OF $ HAVE BFFN AFFIXED TO THE MORTGAGE SECURING THIS NOTE AND CANCELLED. a.{ PRE- CONSTRUCI'1ON CONFERENCE REPORT READ CAREFULLY BEFORE SIGNING (WE) THE UNDERSIGNED HAVE ON THIS DATE PARTICIPATED IN A PRE - CONSTRUCTION CONFERENCE WITH THE CONTRACTOR PRIOR TO THE SIGNING OF A CONTRACT FOR THE REHABILITATION OF MY (OUR) PROPERTY. WE ACKNOWLEDGE THAT WE UNDERSTAND THE TERMS OF THE CONTRACT, THE EXPLANATION OF THE WORK TO BE PERFORMED BY THE CONTRACTOR, THE ROLE OF THE CONTRACT ADMINISTRATOR OF THE REHABILITATION LOAN PROGRAM, AND OUR RESPONSIBILITIES DURING THE CONSTRUCTION PHASE. I (WE) HAVE BEEN GIVEN AN ADEQUATE EXPLANATION TO OUR QUESTIONS, IF ANY, AND ARE AWARE THAT ASSISTANCE WILL BE PROVIDED BY THE STAFF OF THE REHABILITATION LOAN PROGRAM IF REQUESTED. WE FURTHER UNDERSTAND AND ACKNOWLEDGE THAT THE REHABILITATION LOAN PROGRAM AS UMES NO PONSIBILITIES FOR THE WORK PERFORMED. j /..' -u - le i. �� G - s 3- 7- b Signature of Property Owner C � ,�'rop A ess Fk 3.2.2_63 Date . , I, THE UNDERSIGNED, HEREBY CERTIFY THAT THE PRE - CONSTRUCTION CONFERENCE WAS HELD ON THE ABOVE DATE BETWEEN THE HOMEOWNER(S), REHABILITATION LOAN PROGRAM CONTRACT ADMINISTRATOR AND MYSELF. I UNDERSTAND THE PROCEDURES TO BE FOLLOWED FOR CHANGE ORDERS AND REQUESTS FOR PAYMENT. I UNDERSTAND AND AGREE THAT THE WORK PERFORMED MUST MEET THE STANDARDS OF PERFORMANCE REQUIRED BY THE REHABILITATION LOAN PROGRAM AND ESTABLISHED BY THE REHAB STANDARD PERFORMANCE MANUAL 1/ 1( e r-- Signature o on tor Title Date I, THE UNDERSIGNED, HEREBY CERTIFY THAT I PARTICIPATED IN A PRE - CONSTRUCTION CONFERENCE THIS DATE AND THAT I HAVE COMPLIED WITH ALL OF THE PROVISIONS OF THE REHABILITATION LOAN PROGRAM PROCEDURAL MEMORANDUM #49. . ,re , ,, . Si of Rehab Specialist Date NOL`12 51 PO t4 6 1 RE #171754 -0000 QUIT CLAIM DEED OFFICIAL RECORDS to cr n: THIS INDENTURE, made this 27th day of January, 1992 ca.. between SCOTT R. STEWART and ANA C. STEWART, his wife, 78 iii r" Forrestal Circle South, Atlantic Beach , FL 32233, of the County r - " of D uva l a nd the State of Florida, parties of the first part, and I r c; ANA C. STEWART, his wife, 78 Forrestal Circle South, Atlantic r- a Beach, FL 32233, of the County of Duval and the State of Florida, party of the second part, w ~ °C W I T N E S S E T H: w x Z That the said party of the first part, for and in consideration of the sum of Ten Dollars ($10.00) in hand paid by the said party of the second part, the receipt whereof is hereby acknowledged, has remised, released and quitclaimed, and by these presents does remise, release and quitclaim unto the said party of the second part all the right, title, interest, claim and demand which the said party of the first part has in and to the following ;# described lot, piece or parcel of land, situate lying and being in the County of Duval, State of Florida, to wit: v Lot 4, Block 2, ATLANTIC BEACH VILLA, UNIT NO. 1, according to plat thereof recorded in Plat Book 30, Page 56, of the current public records of Duval County, ,,w i�''_.. N Florida. c~- -vr; I ca stm TO HAVE AND TO HOLD, the same, together with all an4rr q .a singular the appurtenances thereunto belonging or in anywise O \I c+ appertaining and all the estate, right, title, interest and clai ,V; t.0 whatsoever of the said party of the first part, either in law o- t2:(.0 equity, to the only proper use, benefit and behoof of the sai,�'„°, n _4 party of the second part. y , 0 CO IN WITNESS WHEREOF, the said party of the first part has hereunto set their hands and seals the day and year first above written. Signed, Sealed and Delivered w NJ in Our Dresence: r 1 // - / , , , • `' i/ 1 . r. /_ -1■40 /J .sir N Pri —"Fie- WIL "'' G. NOE, JR. SCOTT R. EWART 53 -.4 n in 3 4 8 a 7 1 printed Name: GINA HUT /NGS ANA C. S EWART w I 111111111 ° DM m o r H STATE OF FLORIDA 1111 „DC> COUNTY OF DUVAL � 2 1 m ,,m The foregoing instrument was acknowledged before me so Z r.+ m this 27th January, 1992 by SCOTT R. STEWART AND ANA C. STEWART, ID ..�.00 h4 c c.wi fc tahn 4c r �crar v 1 1 r lrnnTan 4-n me nr rahn hma r-rnrlrnr.c.4 f,S - t - ri r CITY OF ATLANTIC BEACH J S BUILDING AND PLANNING r 800 SEMINOLE ROAD Std l r ATLANTIC BEACH, FLORIDA 32233 -5445 TELEPHONE: (904) 247 -5800 FAX: (904) 247 -5845 http://ci.atlantic-beach.fl.us December 7, 2004 Anna Rivera tit 78 Forrestal Lane, South il Atlantic Beach, Florida 32233 1tCO Re. Repayment of CDBG funds Dear Ms. Rivera: I write in reply to your questions regarding the possible need to sell your home due to your husband's Change of Duty orders. The CDBG grant funds spent to renovate your home, in the amount of $31,093.50, were part of the City's 2000 -2001 Housing Rehabilitation program. As you know, these funds are a combination interest -free loan and grant. The amount of this loan is reduced by ten percent of the original amount each year. In other words, if you live in your house for ten years, you will owe nothing back to the City. If for any reason, however, during those ten years, you should have to sell or rent your house, the balance of any money due at that time would have to be re -paid to the City. We are entering the fourth year following renovation to your home, so approximately $18,667 of the original balance would remain due as of January 2005. A future owner could also assume responsibility for the remaining unpaid balance, provided that the new owner met the income and eligibility requirements, and signs an agreement for any remaining balance. These are Federal HUD requirements, and the City does not have the ability to waive the terms of our CDBG contract. If you should in fact need to sell your home, please contact me at 247 -5826 so that I can assist you with this process. Sincerely, at4AA Sonya B. oerr Community Development Director OFFICIAL CHANGE DUTY ORDERS FOR GSM2 JOSE ANGEL SUAREZ , USN 0000 / ••• • ••••• •••••••• • •• • ■■ ••• •••••••• f ■ •••••• IN CARRYING OUT/PROCESSING THESE ORDERS, BOTH PARTS 0 «e MUST BE READ AND LISTED INSTRUCTIONS COMPLIED WITH. • •• ••••••• •••• ■■ ••••• • ••• • • • • ■• •••••• PAGE 02 RUCCBWF3331 UNCLAS PART ONE -- ---- DETACHING ACTIVITY (M) - -- - - -- WHEN DIRECTED DETACH IN MAR 05 EDD: MAR 05 FROM CG 66 HUE CITY UIC: 21656 HOMEPORT MAYPORT, FL FROM DUTY ACC: 100 PERSONNEL ACCOUNTING SUPPORT: CG 66 HUE CITY UIC:21656 - -- - - -- INTERMEDIATE (01) ACTIVITY (S) -- ---- REPORT NLT 20 MAR 05 BUT NET 19 MAR 05 EDA: 19 MAR 05 TO S NAVTECHTRACEN LACKLAND AFB UIC: 35419 LOCATION: SAN ANTONIO, TX FOR TEMPORARY DUTY - UNDER INSTRUCTION ACC: 341 FOR APPROXIMATELY 028 DAY(S) PERSONNEL ACCOUNTING SUPPORT: PERSUPPDET CORPUS CHRISTI UIC: 43100 TO INCLUDE 026 DAY(S) AT CORRECTIONS ASHO CLASS: 50501 CONV: 21 MAR 05 GRAD: 15 APR 05 ENEC: 9575 CDP: 572B UPON COMPLETION OF TEMPORARY DUTY - UNDER INSTRUCTION AND WHEN DIRECTED, DETACH. EDD: 15 APR 05 PAGE 03 RUCCBWF3331 UNCLAS - - - ---- ULTIMATE ACTIVITY (S) - -- - - -- REPORT NOT LATER THAN 22 MAY 05 EDA: 22 MAY 05 TO NAVCONBRIG CHARLESTON SC UIC: 45610 PERMANENT DUTY STATION CHARLESTON, SC. FOR DUTY ACC: 100 ASSIGNED RATE: GSM2 DNEC1: 9575 DNEC2: PRD: 0806 PERSONNEL ACCOUNTING SUPPORT: PERSUPPDET WPNSTA CHASN s H ir .j, CITY OF ATLANTIC BEACH i, „l 8 SEMINOLE ROAD `° It ATLANTIC BEACH, FLORIDA 32233 -5445 4 ' - TELEPHONE: (904) 247 -5800 ,, s .) FAX: (904) 247 -5877 ±} ; a �` SUNCOM: 852 -5800 ' - http: / /ci.atlantic- beach.fl.us ^-,04119 ....) January 14, 2002 Anna Rivera 78 Forrestal Lane South Atlantic Beach, Florida 32233 Re: Verification of income for 2001 CDBG grant recipients Dear Ms. Rivera: The City of Atlantic Beach is in the process of wrapping up our files for houses that were renovated as part of last year's Community Development Block Grant (CDBG) project. Federal auditing regulations require that we have proof of income eligibility for all recipients of grant funds. In reviewing our files, we have discovered that this information has not been kept as required or has been mis- filed. Please bear in mind that your eligibility to have received grant funds for renovation of your residence is not in question. This was determined prior to work being done on your house. In order comply with these audit requirements, please provide a copy of your Tax Return for the year 2000, or some other document that verifies your income. If you wish to come by City Hall, I will be glad to make a copy of this for you, or you may return a copy to me in the envelop provided. I appreciate your help, and please feel free to call me at 247 -5817 with any questions. Sincerely, is-t-giff A r, Sonya B. Doerr Community Development Director JAN. 16.2002 12:39PM P 3 FROM : 0000 PHONE NO. : 9042491142 , D.partment of the Thum" Internal Ravanu• Bonito Form income Tos Return for Singte and 104.0EZ Joint Fliers With No Dependents t'l 2000 OM No. i64642616 Yes S u e t name end initial �----�, L o o t name ss.sa Y o u r *tidal security number use It a � l � a &et r i a t e s o d I n a V et name / ? 3 %L 6 I / g , OW 'the e IRS Mono Moto (IIUR*Rtnd f oe. 1. •os . �° t t. wt. no. Spat,. social security number ?IF por'/Ie'•�ss� C m/s Spa `• i.. here Cle, tow' of post s eoe, oral.. and r ; ,P cods If you terse a boon atom on pogo 12. • .;, Ai is ntic 73e441 FL. ,3201.3 3 . itcesk set w Note. ChoskIng' Yo? will cot dunes your for or seduce your roAted. C�t ,lo (41.12) Do you, or *poem if a joint return, want $8 to go to this find? ► Inbrcttne 1 Total wages, sabres, and tips. This q Attar h should be shown in sett 1 of your / 4t $ 1 . g z 1'�anrde> W`2 1brm(s). Attach your W-2 9 8srm(s), . .1 &d here. ete. but Faemia�o interest. Ir the tend is over aeon, you cannot use O O p d Enol do no aaeaii. soy !homing. 3 Unemployment compensation. qualified state tuition dividends arts and Alaeta Permanent Fund $ O O 000 O o u 1 4 Add lines 1, 2, and S. T la is your adjusted prose 1 [y 1 3 • g ` r b � loom, 4 ( 1 tC Notre. You s 'a� ren pats (o: someone else) claim you on their return? unapt check Yea Enter Recurs No. If single, enter 7,200.00. 7 . a o 0 o c7 from wortmheet If married, enter 12,960.00. Yea a he on book. V See beck fin explanation. 5 6 Subtract line fh from line 4. If line 6 is larger time ' '7 6 4 3 g 1 , line 4, enter 0. This is your taxable inorans. ► 6 ' Payments 7 Enter your Federal income tea withheld from box 2 of I 6 0 (.{. 3 rr arat tax your w -2 form•:a). 7 i 6a Earned income credit (EIC). See page 16. b Nentatable earned income: enter type end amount below. Typo • 0 0 d t7 La t3e 9 Add Huss 7 end 8s_ These are your total payments. 9 • 6 0 it— 3 7 10 Taez. Uee the rtmotmt on line 8 above to find your tax in the tax table on papa 34.28 of the booklet. Then. ! / 3 1 0 0 enter the tax from the table on this line. 10 . Refund 11a wine 9 is larger than line 10, subtract line 10 from t1 •. 5 3 3 Haw it line 9. This ie your refund. 110 4 dire( depooitedi til See ► b Routing number ■ per,; 20 cad • o Ty d Account ell is 1 11b, Cbh�eeakhts Swno number lie, and 11d. 1 + • Mnoount u Mine 10 is larger than line 9, subtract line 9 from Has yaw ,ewe 10. ,hie ie the artruultt you owe. flee page 21 for • d______ etai4 on how to Day 12 1 be v, roof test moan. De 410 d.tdtorr,1 ae.lem that to me toot flew det•t sad b.1W, the 1` m • .alu b teue, •ere.w,,.ad aacur.tsty Ms all a,.ermex sea souroo of !seats. 1 voeat..a de the ta: rum S For kit 10 Y a *wok tQa41wre giant porn. 8041 two 11. mu • hone j Uee . Keep 0 DPY kr Ddo oau st,m Data rpouses �, 1 Only Font reoomdn. • 9... ��: p ' 1.,.. May the IRS discuss this return with the preaarer shown on back Gee page 21)7 Far Disolawre, Privacy Act, and 'Pt per work Reduction Act Nodes, ems page N. Cot.t.,aattn 2000 Porn 104 010 HP Fax Series 900 Fax History Report for Plain Paper Fax /Copier Jan 16 2002 12:20pm Last Fax Date Time Type Identification Duration Pages Result Jan 16 12:17pm Received 1:58 3 OK Result: OK - black and white fax FROM 0000 JAN.16.2002 12:36PM P 1 PHONE NO. : 9042491142 l it.) C 1+1 0 (I- TA 8461 City of Atlantic Beach CDBG Housing Rehabilitations FY 2000/01 Recipient Address Amount Spillers, E. 751 Sailfish Drive $31,190.01 Rivera, A. 78 Forrestal Circle N 31,093.50 Blake, C. 464 Irex Road 28,530.51 Rouse, N. 860 Amberjack Lane 15 160.80 Wright, C. 41 Ardella Road 8,747.00 Total $114,721.82 cdbg01rehabs CONTRACTOR PAYMENT REQUEST I11� l2 l/e�'0 �.�� 3 Homeowner: . ,, . .r . Addrtss: 7e ./y1.--siort G 4Q Ai „, 3396 Complete/it , Atlantic Brmch, Florida 32233 Payment #3 -1 fi . Complete Contractor. S afi S 1 g 1Closa/ Y Amount Requested , / c' ' C o n t r a c t o r . I h e r e b y request an i n s p e c ti o n t o r e c e i v e p a y m e n t # 1 f o r t h e amount o f / / / r 4 - - - - I certify that I have satisfactorily completed the necessary work to justify this ruest and that all bills incurred for labor used and materials furnished in malting said repairs and improvements have been paid in full to this date. Attached is a description of the work completed and the amount of payment requested by work item. `� Contractor's Signature: Date: (V - ao - 0 / it • Homeowner I/We hereby agree that the work stated by the contractor has been completed and approve payment to the contractor in accordance with the contract and contingent upon inspection and concurrence by the Rehabilitation Inspector. It is understood that the actual amount disbursed will be based on the findings of that inspection. ✓*” 7, / Owner's Signature ,i.,t_ . Date: O 9/d ,-/ 0/ Rehabilitation Inspector. I hereby certify that I exercised reasonable care to determine that the work performed at the above address meets specifications and was completed in a satisfactory manner however, neither the undersigned nor Jacksonville HUD is in any way responsible for the acts or omissions of the contractor, any subcontractor, or any of the contractor's agents or employees, or any other person performing work under the construction agreement. The contractor has provided a release of all liens, if any, in connection with this contract and has provided the property owner with a copy of each warranty or guarantee due the property owner from the contractor for work performed. / V Rehab Inspector. _� /- ;/ • X 11, :! Date: l a V Approved. F. . to Finance Department for payment this date. Date Director, Rehabilitation ' • ■ Program Date — i D — D ( • oup # / Req # PO # ,5a 1L C -, — 1 00. Am • , nt ,i t Approves • a - .r • fc�'� ;j .. • L ';i c ;i . Approval / Date ellb A o 1 C; ': i Approval 9 - - `. i . • , r (~ CONTRACTOR PAYMMT REQUEST Li i'vg- i - 3 Homeowner: Ma L.. /,S•/viOt Payment 41 - 3396 Complete _ Address:. / -„/f t 'f /(C, 5 - Payment 42 - 33% Complete • A Atlantic Beach. P1orida 82233 Payment 43 -100% Complete 73/2° Contractor. 52i,7 $ - k gnei6(2 'te( Amount Requested $ 73/2 • Contractor: I hereby request an inspection to receive payment 4 3 for the amount of $ 7 1 /7 . o- . I certify that I • have satisfactorily completed the necessary work to justify this request and that all bills incurred for labor used and materials furnished in making said repairs and improvements have been paid in full to this date. Attached is a description of the mpleted . • amount of payment requested by work item. Contractor's Signalmen: Date: Q a - 2/- c/ y Homeowner I/We hereby agree that the work stated by the contractor has been completed and approve payment to the contractor in accordance with the contract and contingent upon inspection and concurrence by the Rehabilitation Inspector. It is understood that the actual amount dis be the findings of that inspection. /� �J Owner's Signrature / G !o /� /' Q f( . - -- Date: • • Rehabilitation Inspector, I hereby certify that I exctt:ised reasonable care to determine that the work performed at the above address meets specifications and was completed in a satisfactory manner however, neither the undersigned nor Jacksonville HUD is in any way responsible for the acts or omissions of the contractor, any subcontractor, or any of the contractor's agents or employees, or any other person perfomning work under the construction agreement. The contractor has provided a release of all liens, if any, in connection with this contract and has provided the propert owner with a copy of each warranty or guarantee due the property owner from the contractor for work performed. Rehab Inspector. ../ - I ; -' — '� / Date: Approved. Forward to Finance Department for payment this date. JUN 2 Z0111 . CK #U'Jd1 \ `� ' Date , - 4 . = Director, R ilitation an og \ a te � n ^ �`I — � L RECEIVED G # Raq # / PO # JUN Z 7 2001 Amou . t A/P DEPT Approval / D.:.e Approval / Date O . Z. 0 ( • Approval / Date ' 44111 m' - • • CHAN GE Date of Contract 03 -0 7 C/ D ns-e2s Owner Nance: /7/1a e ve/ci Property Address: ;, �, /'e'sfa(/ C : C- Contractor Name: SGr/7 5 %P 1e / C. • Contractor Address: .. ii/4Ye 1-/T 77 to y2073 Phone Number 1 ©' g - re" ,Dcscriution of Work Chanee: AMOUNT: CATEGORY: (Please Type) - 4 114l 1st. _ • �'• i i "7-115.144(f !Veg../ k,7 rn Cctbi keff . /r i/ /( W e i✓ / /cuv 4q ! ki e 4 - /ak c 'et .. n/`Adi g q c° kepiove wail Owl ! eJ ie45* oknej JAN& 1-e io l9'Jd ke /Q ce fry 5irl yie •s1 L' 4-Op and (dal rbieo ce4S !VI r5c SUM Changes and work affected hereby, are subject to all contract stipulations and covenants. This Change Order is made a part of the contract dated first above, parties have hereunto set their signatures. $ p C /i3/ a. 4 Contract Price ✓ $ 3 l / 3,40 Total Owner Approval 1 . r _ _ Date:. _ j d .-0 C o n t a c t o r . • --- Date: 6 - -0 1 Rehab Specialist Approval: _ -.► Da Date: l f - 0 / Pro � Admini x Ma r F re: 6 - � Date b Ke lfr t Source of Fundy $ $ s Group ## / Reel # / Asa Contingency Owner Cons act� a ou Copy. Owner, Contractor, Loan file, Tedmical file, Financial Institution Rf contract prim c Ap p rc 1 / Da to C 1. a rte of changes: Approval / Date • /6 �s � 2. Time extension Approval / Date 3. Deletions of non - required items or unusual allowances 4. Required items that were missed on initial inspection 5. Equal substitution of material or alternative cure for deficiency at same or less pie A D 6. Totally unforeseen circumstances arising after coounencement of work L 1 1 ltlu7 CK # �u liuval County Property Appraiser - Parcel Summary Page 1 of 2 'Parcel Summary - Values from the 2001 Certified Tax Ro111 I IRE No.: 11171754 0000 I 'Owner's Name: IISTEWART , ANA C 1 Property Address: 178 FORRESTAL CR S lUnit No. !ATLANTIC BEACH 1132233 I 'Mailing Address:1178 FORRESTAL CR S I 'ATLANTIC BEACH , FL 1132233 -3326 1 'Property Use: 110100 SINGLE FAMILY I Legal 130 -056 38- 2S -29E ATLANTIC BEACH VILLA UNIT NO 1 LOT 4 BLOCK description: 2 I 1 Neighborhood: 943809 ATLANTIC BEACH VILL NBHD Sec -Twn- Range: 17 -2S -29E IOR BK & Page: 1107257 -1461 Map Panel: 556A3 Sale Date: 11/27/1992 No. Buildings: 1 Sale Price: 1$20,500.00 Land Value: 1$13,350.00 Heated Area: 1437 Class Value: $0.00 Exterior Wall: CONCRETE BLOCK Improvements: $42,102.00 Taxin USD3 Authority: !Market Value: $55,452.00 County Tax: $193.41 !Assessed Value: $52,411.00 School Tax: $227.01 Exempt Value: $25,000.00 District Tax: $83.12 Taxable Value: $27,411.00 Other Tax: $13.72 Sr. Exempt: 1$0.00 Voted Tax: $16.75 Sr. Taxable: 1$0.00 Total Tax: $534.01 This page displays values from the 2001 Certified Tax Roll with weekly updates of ownership & sales. Map -It maps & data are updated & maintained by COJ -GIS, not the Property Appraisers Office. Please direct inquiries regarding the maps & data to Map -It Feedback (below), not the Property Appraisers Office. http://pawww.coj.net/pub/property/RENO.asp?RENUM=171754+0000 2/6/2002 JAN. 16.2002 12:39PM P 2 FROM : 0000 PHONE NO. : 9042491142 CITY OFATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH. FLORIDA 32233 -544 TELEPHONE: (904) 247 -5800 �'1 FAX: (904) 247 -5877 t" SUNCOM: 852 -5800 http: / /cl.etlantic- beach.fl.us January 14, 2002 Anna Rivera 78 Forrestal Lane Sout h Atlantic Beach, Florida 32233 Re: Verification of income for 2001 CDBG grant recipients Dear Ms. Rivera: The City of Atlantic Beach is in the process of wrapping up our files for houses that were renovated as part of las year's Community Development Block Grant (CDBG) project. Federal auditing regulations require that we have proof of income eligibility for all recipients of grant funds. In reviewing our files, we have discovered that this information has not been kept as required or has been mi s -fi led. Please bear in mind that your eligibility to have received grant funds for renovation of your residence is not in question. This was determined prior to work being done on your house. In order comply with these audit requirements, please provide a copy of your Tax Return for, the year 2000, or some other document that verifies your income. If you wish to come by City Hall, I will be glad to make a copy of this for you, or you may return a copy to me in the envelop provided. I appreciate your help, and please feel free to call me at 247 -5817 with any questions. Sincerely, ?L'ef 1 Sonya B. Doerr Community Development Director • • • • • I