1
2
Number of pages
This document will be public
record. Please remove all
Social Security Numbers
prior to recording.
Deed / Mortgage Instrument
Deed / Mortgage Tax Stamp
Recording / Filing Stamps
3
FEES
Mortgage Amt.
Page / Filing Fee
1. Basic Tax
20. 00
Handling
2. Additional Tax
Sub Total
TP-584
Spec./Assit.
Notation
or
EA-52 17 (County)
Sub Total
Spec. /Add.
TOT. MTG. TAX
EA-5217 (State)
Dual Town
Dual County
R.P.T.S.A.
Held for Appointment
5. 00
Comm. of Ed.
Transfer Tax
Mansion Tax
Affidavit
The property covered by this mortgage is
Certified Copy
or will be improved by a one or two
family dwelling only.
15. 00
NYS Surcharge
Sub Total
YES
or NO
Other
If NO, see appropriate tax clause on
Grand Total
page #
of this instrument.
4
5
Community Preservation Fund
Dist.
Section
Block
Lot
Consideration Amount $
Real Property
Tax Service
$
Agency
CPF Tax Due
Verification
Improved
Satisfactions/Discharges/Releases List Property Owners Mailing Address
6
RECORD & RETURN TO:
Vacant Land
TD
TD
TD
Title Company Information
Mail to: Judith A. Pascale, Suffolk County Clerk
7
310 Center Drive, Riverhead,
NY 11901
Co. Name
Title #
Suffolk County Recording & Endorsement Page
8
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 TOWN of
In the VILLAGE
or HAMLET of
BOXES
THRU
MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING.
6
8
(over)