HomeMy WebLinkAboutV 2023-0004; MCGERVEY KITCHEN ADDITION/GARAGE VARIANCE; Variance (V)7
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8 Fidelity National TI tie Company STATEMENT OF INFORMATION
CONFIDENTIAL INFORMATION
FOR YOUR PROTECTION
Escrow No.: 9922305215
Completion of this statement expedites your application for title insurance, as it assists in establishing identity, eliminating matters affecting
persons with similar names and avoiding the use of fraudulent or forged documents. Complete all blanks (please print) or indicate "none" or
"NIA" If more space is needed for any item(s), use the reverse side of the form. Each party (and spouse/domestic partner, if applicable) to
the transaction should personally sign this form.
First Name Middle Name
NAME AND PERSONAL INFORMATION
Last Name
(If none, indicate)
Malden Name
Date of Birth _______ _
Home Phone _________ Business Phone ________ Birthplace __________________ _
Cell Phone _________ Fa, _________ Email _______________________ _
Social Security No. _________________ Driver's License No. __________________ _
List any other name you have used or been known by ______________________________ _
State of residence _____________________ I have lived continuously in the U.S.A. since ______ _
Are you currently married? 0 Yes O No Are you currently a registered domestic partner? D Yes O No
If yes, complete the following information:
Dale and place of marriage---------------------------------------
Spouse/Domestic Partner ________________________ _
First Name Middle Name Last Name Maiden Name
(If none. indicate)
Date of Birth ________ _
Home Phone ________ Business Phone ________ Birthplace ________________ _
Cell Phone _________ Fa, _________ Email _____________________ _
Social Security No. ________________ Driver's License No. __________________ _
List any other name you have used or been known by ____________________________ _
State of residence ___________________ I have lived continuously in the U.S.A. since, ______ _
CHILDREN
Child Name: ___________ Dale of Birth: ____ Child Name: _________ Date of Birth: _____ _
Child Name: Date of Birth: Child Name: Date of Birth: _____ _
(if more space Is required, use reverse side of form)
RESIDENCES (LAST 10 YEARS)
Number & Street City From (date) to (date)
Number & Street City From (date) to (date)
(if more space is required. use reverse side oflonn)
OCCUPATIONS/BUSINESSES (LAST 10 YEARS)
Finn or Business Name Addras.s From (date) to (date)
Finn or Business Name M••" From (date) to (date}
(if more space is required, use reverse side of form}
SPOUSE'S/DOMESTIC PARTNER'S OCCUPATIONS/BUSINESSES (LAST 10 YEARS)
Finn or Business Name
Frnn or Business Name
Statement of Information (UE-34 (Rev. 06--08))
SCA0000279.doc I Updated: 10. 10.19
Address
Ad<Iess
{if more space is required, use reverse side of form)
Page 1
From (date) to (date)
From (date) to (date)
Printed; 08.25.23@ 04:24 PM by
CA-FT-FSDG-01500.071026---9922305215
STATEMENT OF INFORMATION
CONFIDENTIAL INFORMATION FOR YOUR PROTECTION
(continued)
PRIOR MARRIAGE(S) and PRIOR DOMESTIC PARTNERSHIP(S)
Any prior marriages or domestic partnerships for either person? ____ If yes, complete the following:
Prior spouse's (Party A) name: _____________ Prior Spouse of Party A:
Marriage ended by: D Death D Divorce/Dissolution D Nullification Date of Death/Divorce: ____________ _
Prior spouse's (Party B) name: _____________ Prior Spouse of Party B: __________ Spouse
Marriage ended by: D Death D Divorce/Dissolution D Nullification Dale of Death/Divorce: ____________ _
(if more space is required, use reverae side of form)
INFORMATION ABOUT THE PROPERTY
Buyer intends to reside on the property in this transaction: D Yes D No
Owner to complete the following items
Street Address of Property in this transaction: ______________________________ _
The land is D unimproved; or improved with a structure of the following type: DA Single or 1-4 Family D Condo Unit D other ___ _
Improvements, remodeling or repairs to this property have been made within the past six (6) months: D Yes D No
If yes, have all costs for labor and materials arising in connection therewith been paid in full? □Yes □No
Any current loans on property? _____ If yes, complete the following:
Lender Loan Amount ___________ Loan Account No.
,Loao,do•c' ____________ Loan Amount Loan Account N'l. _______ _
The undeniigned declare, under penalty of perjury, that the foregoing is true and correct.
IN WITNESS WHEREOF, the undersigned have executed this document on the date(s) set forth below.
Signature Date
Print Name
Signature Date
Print Name
(Note: If applicable, both spouses/domestic partners must sign.)
THANK YOU.
Statement of lnforma~on (UE-34 (Rev. 06-08))
SCA0000279.doc I Updated: 10.10.19 Paga 2
Printed 08 25.23@ 04:24 PM by
CA--FT-FSDG-01500.071026-9922305215