EFTA00168378¶
CERTIFICATION¶
I certify that all of the items of information entered on this form are true and correct (to the best of my knowledge and belief) and understand that the making of any willful false statement of material fact herein will subject me to the provisions of the penal law relative to the making and filing of false instruments.¶
BUYER 12/27/11¶
BUYER’S ATTORNEY ERIKA KELLERHALS, ESQ¶
BUYER SIGNATURE 9100 HAVENSIGHT, PORT OF SALE, SUITE 15/16.¶
LAST NAME FIRST NAME¶
STREET NUMBER ST. THOMAS¶
STREET NAME (AFTER SALE) 00802¶
AREA CODE TELEPHONE NUMBER SELLER¶
DATE 12/27/11¶
CITY OR TOWN STATE PROVINCE¶
ZIP CODE POSTAL CODE¶
BELLER SIGNATURE¶
DATE¶
2011122700132201¶
USAO 000404¶
EFTA_00018314¶
EFTA00168379¶