Form 12-0104 - Mortgage - Suffolk County
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1
212-0104 (2/99)
1 2
3
Number of pages
TORRENS
Serial # ______________________________
Certificate # __________________________
Prior Ctf. #____________________________
Deed / Mortgage Instrument
Deed / Mortgage Tax Stamp
Recording / Filing Stamps
FEES
4
age / Filing Fee
________ _____
P
Mortgage Amt.
________ _____
Handling
________ _____
1. Basic Tax
________ _____
TP-584
________ _____
2. Additional Tax
________ _____
Notation
________ _____
Sub Total
________ _____
EA-52 17 (County)
________ _____
Sub Total _________________
Spec./Assit.
Or
EA-5217 (State)
________ _____
Spec./Add.
________ _____
R.P.T.S.A.
________ _____
TOT. MTG. TAX
________ _____
Dual Town ________ Dual County ____
Comm. of Ed.
________ _____
5
00
Held for Apportionment _______
Transfer Tax
________ _____
Affidavit
________ _____
Mansion Tax
________ _____
Certified Copy
________ _____
The property covered by this mortgage is
or will be improved by a one or two family
Reg. Copy
________ _____
Sub Total _________________
dwelling only.
YES _____ or ______ NO
Other
________ _____
GRAND TOTAL _________________
If NO, see appropriate tax clause on page
# _____ of this instrument.
5
Real Property Tax Service Agency Verification
6
Community Preservation Fund
Dist.
Section
Block
Lot
Consideration Amount
$ _______________
Stamp
CPF Tax Due
$ _______________
Date
Improved ________
Initials
Vacant Land ______
7
Satisfactions/Discharges/Releases List Property Owners Mailing Address
TD
_________
RECORD & RETURN TO:
TD
_________
TD
_________
8
Title Company Information
Co. Name
Title #
S
C
R
& E
P
9
UFFOLK
OUNTY
ECORDING
NDORSEMENT
AGE
This page forms part of the attached __________________________________________________________________ made by:
(SPECIFY TYPE OF INSTRUMENT)
__________________________________________ The premises herein is situated in
__________________________________________ SUFFOLK COUNTY, NEW YORK.
To
__________________________________________ In the Township of _________________________________________________
__________________________________________ In the VILLAGE or HAMLET of _____________________________________
BOXES 5 THRU 9 MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING.
(OVER)
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