461 Levy Road WELL-SEPTIC CONVERSION App 05.14.2007 R
RECEIVED
CITY OF ATLANTIC BEACH
BUIL DNC R 70NNC
MAY 1 t2OJ17 of Atla is Beach • 800 Seminole Road •Atlantic Beach,Florida 32233-5445
Phan : (904)247-5800 • Fax (904)247-5805 • http://www.coab.us
BY:
- -- – - -- - — APPLICATION FOR ASSISTANCE
WITH CONVERSION FROM
WELL AND SEPTIC TANK TO CITY WATER AND SEWER
2006-2007 COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
The information requested on this form is required in order to determine your eligibility to participate in this
program. (These funds may be available to homeowners whose incomes are within low and moderate levels
based upon family size and as established by HUD Section 8 Income Limits.) Please answer all questions,
and provide copies of all required documents. (Your information is considered confidential.) Funds for this
program are available only for single-family residential houses and for homeowners who live in their home.
(Homes cannot be rental houses.) Grant funds are limited, and applicants are selected based upon most
urgent and serious need and availability of funds.
DATE: 5 — 1+01
1. Homeowner Name(s): SS i C- 1.J .
2. Address of Home: 44
3. Telephone Number:91$ 2,49 Oct I (day) cell L,L.,2,Q 5L 4(..c (night)
4. Is the person completing this application the Head of Household? ❑ yes NI no f X female male
5. How many family members live in this house? o.%
6. Are there people living in this house with disabilities or special needs? ❑ yes ❑ no If yes, please
explain al ' - j,de_ //11
O . . — t.: 0 '4 - _ . - ti; 4 'erg
7. Number and age of persons living in the household in addition to Head of Household.
Ages 0–5 years old Male Female
Ages 6–17 years old Male Female
Ages 18–39 years old Male Female
Ages 40–64 years old Male t,�_ Female
Ages 65 and older (4 9 Male Female
8. Water supply is provided by: ❑City Water 'Private Well Other
9. Does septic system work properly? I I Yes X No If no, please explain. -..f�A__CL4 in e l-t m eS
Page 1 of 3
INCOME VERIFICATION FORM
PART I. (To be filled out by the person (employee) completing this application.)
Applicant / Employee name:
Address: `/ [r./ J 1 L kcg at( dc-(.. 7-14 . 3.22 33
f e ti-us hdiv
Social Security Number: J/e 3 - v %o ,;?�'u 34- ‘1-00
I hereby authorize release of my income information to the City of Atlantic Beach for
the purpose of applying for participation in the Housing Rehabilitation Assistance
Program, which is funded by a Community Development Block Grant.
5-- Pi--— O i
Signature of Owner Date
/5 )/e_ 33
PART II. (To be filled out by employer, Social Security Administration or HRS.)
Please provide the following information and return to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
Applicant / Employees Name:
Gross Monthly Income: $
Is employment: permanent part-time temporary
Employer Name:
Address: Telephone:
Name and title of person providing this information. Date
Page 3 of 3
10. Does your plumbing work properly? . Yes ❑ No
If no, please explain.
11. Is there hot and cold running water in your house? 14 Yes ❑ No
12. Do you have a complete kitchen with running water,a refrigerator and cooking facilities? y es
13. How many persons are in your family and living at this address?
14. Federal regulations require that we keep track of certain demographic information and the type of
households being served. Please check the appropriate box below.
.6 White,Not Hispanic
❑ African-American,Not Hispanic
❑ American Indian or Native Alaskan
❑ Hispanic
❑ Asian or Pacific Islander
❑ Female Head of Household
❑ Other
15. What is the total annual income(before taxes) of your household? c7113 q '+ ,o C7
16. Are you on a fixed income such as Social Security,SSI or retirement? 123 Yes ❑ No
17. What are your sources of income? So&i4 h/41L get— ,,,,;c. . Dis4h f-y 55
18. Do you own this home? .1RrYes ❑ No
If you own your home, please provide a copy of your deed and a recent water or electric bill which shows that
you live at this address. If you rent your home, please provide a copy of the lease.
Signature of Owner Date
If you have any questions about this application or need any assistance preparing
the application, please contact the City of Atlantic Beach at (904) 247-5826.
The attached Income Verification Form must also be completed and mailed to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
In order to arrange to inspect your home for needed repairs, please provide the time of day and
day of the week (Monday through Friday) when it would be most convenient to make
arrangements for a Building Inspector to meet with you, and the phone number where you wish
to be called.
c.24 ?097t—
Page 2 of 3
Do Not Return This Notice to the SSA or the IRS
FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT rom
'les,
f t,Or
2006 •• PART SEE TORE YOUR
FOR SECURITY
INFORMATION.SHOWN IN BOX 5 MAY BE TAXABLE INCOME. tring
MORERAs,
ince
Box 1.Name Box 2.Beneficiary's Social Security Number etc.
BESSIE L TEBOE 263-66-0109
_
Box 3.Benefits Paid in 2006 Box 4.Benefits Repaid to SSA in 2006 Box 5.Net Benefits for 2006(Box 3 minus Box 4) m r 2
$6,830.00 NONE $6,830.00 vi
N
,is copy
DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4 co
5 lhyour
city,or
Paid by check or direct deposit $6,830.00 NONE J income
u) 1,when
Benefits for 2006 $6,830.00 quires.
o Service
Box 6.Voluntary Federal Income Tax Withheld
=rom
NONE ities,
it, or
aring
Box 7.Address RAs,
BESSIE L TEBOE ance
461 LEVY ROAD ,etc.
ATLANTIC BEACH FL 32233-2617
yB
n
= income
m leral tax
N is form
Box 8.Claim Number (Use this number if you need to contact SSA.) 9 Feal
thheldder
to ich this
263-66-0109A m r return.
ry
v
' atemaf
being
Form SSA-1099-SM(1-2007) DO NOT RETURN THIS FORM TO SSA OR IRS
ie Service
Control Number
RET0460550 ❑ CORREI; _
PAYER'S name,street address,city,state,and ZIP code 1 Gross distribution ..-,,,,, .., ..,-.,i ly Distributions From
DEFENSE FINANCE AND ACCOUNTING SERVICE Pensions,Annuities,
Retirement, or
US MILITARY RETIREMENT PAY $ 6854.942a06 Profit-Sharing
PO BOX 7130 2a Taxable amount Plans, IRAs,
LONDON KY 40742-7130 Insurance
$ 6854.94 Contracts,etc.
PAYER'S Federal identification number RECIPIENT'S identification number 2b Total Form 1099-R
34-0727612 280-34-4007 distribution ❑
RECIPIENT'S name,street address,city,state,and ZIP code 4 Federal income tax withheld 7 Distribution code Copy C
For Recipient's
$ 7 Records.
This information
9 Your percentage of total distribution is being
DONALD E TEBOE % furnished to the
461 LEVY RD 10 State tax withheld 11 State/Payer's state no. Internal Revenue
ALTANTIC BEACH FL 32233-2617 $ Service.
Keep this copy
RETIRED 01012006-12312006 for your records.
Form 1099-R Department of the Treasury-Internal Revenue Service 400i
rom
__ _ - omuulil TY BENEFIT STATEMENT 'ies,
t,or
2006 • PART•SEE THEOF
ROEVERSUR OE CIAL FOR MORE SECURITY
INFORMATION.BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME. 'As
nce
Box 1.Name etc.
Box 2.Beneficiary's Social Security Number
DONALD E TEBOE 280-34-4007
Box 3.Benefits Paid in 2006 Box 4.Benefits Repaid to SSA in 2006 Box 5.Net Benefits for 2006(Box 3 minus Box 4) /2
$16,734.00 NONECD
$16,734.00 • 's copy
▪ n your
DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4 a city,or
mincome
Paid by check or direct deposit $14,575.20 NONE 2 ,,when
Medicare Part B premiums deducted • quires.
from your benefits $1,062.00
Voluntary Federal Income
Tax Withheld $1,096.80 Service
Total Additions $16,734.00
Benefits for 2006 $16,734.00
Box 6.Voluntary Federal Income Tax Withheld -
-rom
ities,
$1,096.80 it, or
aring
RAs,
Box 7.Address ance
DONALD E TEBOE ,etc.
461 LEVY RD
ATLANTIC BEACH FL 32233-2617
. yB
income
c
leral tax
m is form
N Federal
Box 8.Claim Number(Use this number if you need to contact SSA.) -j ,thheld
ich this
280-34-4007A return.
nmi u Deina
N ntemaf
Form SSA-1099-SM(1-2007) DO NOT RETURN THIS FORM TO SSA OR IRS
ie Service
Control Number
RET0460550 ❑ CORREI,
PAYER'S name,street address,city,state,and ZIP code 1 Gross distribution ,� �,,a Distributions From
DEFENSE FINANCE AND ACCOUNTING SERVICE Pensions,Annuities,
US MILITARY RETIREMENT PAY $ 6854.94 Retirement, or
2006 Profit-Sharing,
PO BOX 7130 2a Taxable amount PlanssIRAs,
LONDON KY 40742-7130
Insurance
$ 6854.94
Contracts,etc.
PAYER'S Federal identification number RECIPIENT'S identification number 2b Total Fom 1099-R
34-0727612 280-34-4007 distribution ❑
RECIPIENT'S name,street address,city,state,and ZIP code 4 Federal income tax withheld 7 Distribution code Copy C
For Recipient's
$ 7 Records.
•
9 Your percentage of total distribution This information
is b
DONALD E TEBOE % furnished toeing
ethe
461 LEVY RD
ALTANTIC BEACH FL 32233-2617 1$0 State tax withheld [11 State/Payers state no. Internal Serviue
ce.
Keep this copy
RETIRED 01012006-12312006 for your records.
Form 1099-8 Department of the Treasury-Internal Revenue Service 4007
WELL AND SEPTIC TO WATER / SEWER
CONNECTION AGREEMENT
CITY OF ATLANTIC BEACH,
COUNTY OF DUVAL, STATE OF FLORIDA
ADDRESS AND LEGAL DESCRIPTION OF PROPERTY:
For the value of services received, which may include, abandonment of existing
septic tank, construction of the connection, the sewer tap fee and any impact fees
related to connection of this property to centralized sewer services, the undersigned
promises to pay, in accordance with the following terms of this Agreement, to the
City of Atlantic Beach, hereinafter known as the Holder of this Agreement, which
is a municipality of the State of Florida, located at 800 Seminole Road, Atlantic
Beach, Florida 32233, the principal sum of:
($ •_)
being payable in lawful currency of the United States of America to the Holder at
800 Seminole Road, Atlantic Beach, Florida 32233, or at other such address as the
Holder may specify by written notice to the Maker. Said sum shall bear no interest
and shall be reduced in amount at the rate of one/tenth (1/10th) per year, on each
year anniversary of this Connection Agreement, until reduced to a balance of zero
(0) dollars at the end of ten years. Any unforgiven balance shall become
immediately due and payable in the event that the Maker transfers title of
ownership or moves from the premises, which secures this Connection Agreement
within the ten (10) year period of time. In the event of the death of the Maker of
this Agreement, said Agreement shall remain in effect and the principal sum that is
due shall be reduced as described above only in the case that an immediate family
member, with qualifying income eligibility, takes residence upon the premises,
which secures this Agreement. In all other cases, and under any other
circumstance, any unforgiven balance shall become immediately due and payable
to the Holder.
Page 1 of 2
This Connection Agreement is to be construed and enforced in accordance with the
laws of the State of Florida, and is secured by the real property, located at:
In the event that default is made in the payment of any of the sums as described
and required herein, or in the performance of any agreements contained herein,
then at the option of the Holder of this Rehabilitation Agreement, the remaining
principal balance shall immediately become due to the Holder and collectable
without notice, time being of the essence of this Rehabilitation Agreement
contract, and said remaining principal balance shall bear interest at the highest rate
allowed by applicable law, from such time until paid in full.
Each Maker and Endorser waives presentment, protest, notice of protest and notice
of dishonor and agrees to pay all costs, including reasonable attorney's fees,
whether suit be brought or not, if counsel shall be required after maturity of this
Agreement, and if counsel shall be employed to collect said Agreement or to
protect the security thereof.
Printed Name of Maker:'55 t t L -��U Date: a_ , _0 2
Signature of Maker:
SWORN AND SUBSCRIBED BEFORE ME THIS 8DAY OFA 1(/
STATE OF FLORIDA, COUNTY OF DUVAL
NOTARY'S SIGNATURE
SHIRLEY HIRLEY L. GRAHAM
= Notary Public-State of Florida
pr.` Ay Commission Expires Feb 14,2010
-•';' Commission#DD 518533
Bonded By National Notary Assn.
tot 5
1 Page 2 of 2
l
1
5 1
No. 41507
! ..1
E
5 ABSTRACT OF TITLE K
5 To the following described lands, lying and being in Duval County, Florida: K
5 Parts of Government Lot 4, Section 17, Township 1�
5 2 South, Range 29 East, and being more particularly 1
I described in Deed. Book 1360, page 111, Duval County
Records, and in Deed Book 1425, page 301, Duval
1 County Records.
R
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I I
5 N1
I
15 I
5
I El►
I
. 1
1 SUPPLEMENTARY ABSTRACT E1
1 Certifying onlyfrom February 22nd, 1954 at 8:00 A. M. 1
IE. E
E ►I'
PREPARED BY
i TITLE INSURANCE COMPANY OF THE SOUTH
§
1 120 EAST FORSYTH STREET—TELEPHONE 356-5626
E. JACKSONVILLE. FLORIDA 32202
PA11,1,9.41,VdI.I�/JWJI).9IJWJWJV./JI�JWJWJMIMIN//1=1,9IJVM.%1 PIMVIA/ NMJV.►/.11,1RAPIND /IMIKUP MIWJWJLl MAP IIMIZo,
TICS-1O AMBROSE
-1-
! • .
GIIC—Florida j(� n r
Mortgage. r11GE l.1 O9 PAGE 56`
• THIS MORTGAGE DEED, Executed the 11th day of February A. D. 19 514
by • ,
ARTHUR SHARPIES and FRANCES B. SHARPLFS, his wife, of the County of Duval, State
of Florida,
• I
hereinafter called the Mortgagors, which,term shall include the heirs, legal representatives, successors I!
and assigns of the Mortgagors wherever the context.so requires or admits, to GULF LIFE INSUR-
ANCE COMPANY, a corporation organized and existing under and by virtue of the laws of the State •
of Florida, hereinafter called the Mortgagee, which term shall include the successors and assigns of
the Mortgagee wherever the context so requires or admits. .
,-
WITNESSES: That for divers good and valuable considerations, and also in consideration of the
aggregate sum named in the promissory note hereinafter described, the Mortgagors do hereby grant,
bargain, sell, alien, remise, release, convey and confirm unto the Mortgagee,the land,of which the Mort-
gagors areUALw seized and and State of Florida,ossessed and in actual describedsasaion,follows,oto-witthe County of
DUVAL
PARCEL A: A part of Government Lot' Four (14), Section 17, Township 2 South, Range 29
Eas , more particularly described as follows:
Commencing at the Southwest corner of Government Lot Four(14), thence run South Eighty-
five (85) degrees Five.(05) minutes East a distance of Three Hundred Sixty and Ninety-
one Hundredths (360.91) feet along the center line of Levy Road; thence run North .
Zero (0) degrees Forty-five (145) minutes West a distance of Thirty-three and Sixteen
Hundredths (33.16) feet to the North right of way line of said Levy Road for a point of
beginning; thence run North Zero (0) degrees Forty-five (145) minutes West a distance
•
of One Hundred Forty-two (1142.0) feet; thence run North Eighty-five (85) degrees Five
(05) minutes West a distance of Sixty-two (62.0) feet; thence run South Zero(0) degrees - '
Forty-five (145) minutes East a distance of One Hundred Forty-two
th1142.0)e feet;
right thence
n South Eighty-five (85) degrees Five (05) minutes East along +
ofway
I ne of said Levy Road, a distance of Sixty-two (62.0) feet to the point of beginning;
IARCEL B: Part of Government Lot Four (14), Section 17, Township 2 South, Range 29 East
ore par icularly described as follows:
ommencing at Southwest corner of said Lot Four (14) and thence run South Eighty-five
Q. ,,(85) degrees Five (05) minutes East a distance of Four Hundred Twenty-two and Ninety- .
°°ane Hundreds (1422.91) feet along the South line of said Lot Four (14) to a point; thence
grin North Zero (0) degrees Forty-five (45) minutes West a distance of Thirty-three and
i sixteenth Hundredths (33.16) feet to a point in the North right of way line of the Levy
'„Road, County Road No. 222, said point being the point of beginning of the herein described
0
Viand; thence run North Zero (0) degrees Forty-five (145) minutes West a distance of
I' ,
' One Hundred Forty-two (1142) feet to a point; thence run North Eighty-five (85) degrees
Five (05) minutes West a distance of Sixty-two (62) feet to a point; thence run South
j -Zero (0) degrees Forty-five (145) minutes East a distance of One Hundred Forty-
two feet
to a point in the North right of way line of said Levy Road; thence run South Eighty-
five (85) degrees Five (05) minutes East a distance of Sixty-two (62) feet along the
North right of way line of said Levy Road to the point of beginning, said lands being
ounded on the West by the lands of parties of second part as described in Deed recorded
... n Deed Book 1360, page 111, current public records, Duval County, Florida.
•
SUBJECT to that certain mortgage dated January 10, 19149, given by Richard P. Clarson,
unmarried, t•o the Mortgagee herein, securing $2,000.00, and recorded in Mortgage Book
12314, page 221, current public records, Duval County, Florida, as to Parcel A.
together with all the buildings and other structures now or hereafter on said land.
TO HAVE AND TO HOLD the same, together with all and singular the tenements, heredita-
ments and appurtenances thereunto belonging or in anywise appertaining, and the rents, issues and t
I profits thereof unto the Mortgagee in fee simple.
... ,, nnvn„n„+ With the Mnrte•agee: that the Mortgagors are indefeasibly
' IT IS MUTUALLY COVENANTED AND AGREED by and between the Mortgagors and the
( Mortgagee that this mortgage and the promissory note secured hereby constitute a Florida contract and
l'''
I shall be construed according to the laws of that State.
•
f IN WITNESS WHEREOF, the Mortgagors have executed these
presents under seal the day
1 and year above written.
ISigned,Sealed n Delivered in the Presence of
r
. /
_ '.....(SEAL)
o h
Sh. pYpie's ..-- -
As
.0009
i• 444,,,,,,,„a____Qii; •
As' Frances H. Sharples
FLORIDA
STATE OF___.__._._--
COUNTY OF_._.---1_ _DUVAL as.
•
•
•
•
I HEREBY CERTIFY, that on this day, before me, an officer duly authorized in the State aforesaid and In the
County aforesaid to take acknowledgments, personal] a ea
ARTHUR SHAR y pp red_____________________.______
ed.------______--_ •_—
PLES husband of Frances --
------
A .UR ----- - _-----------B. Sharples _
to me known to be the person described in and who executed the foregoing instrument and____
acknowledged before me that__he......executed the same. he
WITNESS my hand and official seal in the County and State last aforesaid is
122.day of..___Febrl�ar
A. D. 19.....5.4.. .
x----.
•
Notary Public ..
- My commission expires: .6,,,�C a, X957. •
,.
STATE OF-----FLORIDA
COUNTY OF_____.
DUVAL 8e
I HEREBY CERTIFY, that on this day, before me, an officer duly authorized in the State aforesaid and in the
County aforesaid to take acknowledgments, personale
FRANCES 13, r appeared
— --- —
RPZ,I'S,w,�fe of -yrthux.--Shax'Alea,,-----....------....----------
to me known to be the person described in and who executed the foregoing instrument and....__she
F acknowledged before me that.$he executed the same. •
L
WITNESS my hand and official stal In the County and State last aforesaid this_�(!' ay of__ Februa r- •
A. D. 19 5
958-8, 6, A _.. 2,4)11. .
FEB 22 4 !4 f i 1 I`,154 Notary Public --
My commission expires:
LeC. 2o /
FIXED ArJ rfCO0nt0 1.1 rrpq.0
R[C000s 01 U i COurit.rue
STATE OF_-------_— rows Ann PM;t NO TOOj:EK
COUNTY OF_ t4[ .
PCvsi Cr,.r,r 98.
Before me ------ c t
personally appeared_ i d
:and.___ - ;
land known to me to be the individuals described in and who executes the foregoing instrument ' to me well known, J
President and—___—__Secretary of the above named _
and severally acknowledged to and before me that they executed such instrument as such__ o___ �_
`t CITY OF ATLANTIC BEACH
;>` PURCHASE ORDER
ns PURCHASING
4" ' PHONE (904) 247-5880P.O.NUMBER DATE6/14/07
t:)--4. :41FAX (904) 247-5819
t ` \.. 071982 0
C?.3
THIS P.O.NUMBER MUST APPEAR ON ALL INVOICES,
PACKING SLIPS,LABELS,BILLS OF LADING AND
CORRESPONDENCE.
VENDOR: SHIP TO:
GRUHN MAY INC CITY OF ATLANTIC BEACH
6897 N. PHILLIPS PARKWAY ATTN: PUBLIC WORKS DEPT
JACKSONVILLE, FL 32256 1200 SANDPIPER LANE
ATLANTIC BEACH, FL 32233
VENDOR# DATE NEEDED TERMS REQUISITIONED BY \
439 06/14/07 NET KALUZNIAK
F.O.B CONTRACT NO. ACCOUNT NO. PROJECT REQ.NO. REQ.DATE
0506-16 11010055158300 72204 06/08/07
LINE QUANTITY UOM ITEM NO.AND DESCRIPTION UNIT COST EXTENDED COST
1 1380.60 DL INSTALL WATER SERVICE ON PRIVATE 1.00 1380.60
PROPERTY AT 461
LEVY ROAD, CDBG GRANT FUNDS.
SUB-TOTAL 1380.60
TOTAL 1380.60
REMARKS:
ATTN: GORDON, FAX: 268-0679
\ J
NOTICE I CERTIFY THAT THE ABOVE PURCHASE IS NECESSARY FOR THE
PROPER• RATION OF THE CITY OF ATLANTIC BEACH AND
PLEASE SEND INVOICE TO: THE FU . RE APPROPRIATED IN THE CURRENT BUDGET.
CITY OF ATLANTIC BEACH
ATTN:ACCOUNTS PAYABLE CLERK ci,ty-ex.‘ti• iai<
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233 PURCHASIN AG NT
THE LAWS OF THE STATE OF FLORIDA,U.S.A.,SHALL GOVERN IN
CONNECTION WITH THE FORMATION,PERFORMANCE,AND THE
FEDERAL TAX ID#59-6000267 LEGAL ENFORCEMENT OF THIS PURCHASE ORDER.
STATE TAX EXEMPT#85-8012740083C-8 DEPARTM ENT COPY