DTE 101 Rev. 6/16 STATEMENT OF CONVEYANCE HOMESTEAD PROPERTY To be attached to Conveyance Fee Forms, DTE 100, 100(EX), 100M & 100M(EX) Grantor's (Seller's) Name _______________________________________________________ Grantor's Address _____________________________________________________________ Grantee's (Buyer's) Name _______________________________________________________ Taxing District _________________________________ Parcel, Account or Registration No. _______________________________________________ Complete This Section Only If Real Estate Is Transferred The grantor of the property referred to above states that the property has or will receive the senior citizen, disabled persons, or surviving spouse homestead exemption under Ohio Revised Code section 323.152(A) for the preceding or current tax year. The estimated amount of such reduction that will be reflected in the grantee's taxes is: Preceding Tax Year $_________________ Current Tax Year $_________________ Complete This Section Only If Manufactured or Mobile Home Is Transferred The grantor of the manufactured or mobile home referred to above states that the home received the senior citizen, disabled persons or surviving spouse homestead exemption under Ohio Revised Code section 4503.065 for the current tax year. The estimated amount of such reduction that will be reflected in the grantee's taxes is $_________________ The grantor and the grantee have considered and accounted for the total estimated amount of such reduction(s) to the satisfaction of both the grantee and the grantor. ___________________________________ Signature of Grantor or Representative Sworn to or affirmed in my presence, this _____ day of ___________________________ ________ (year). ___________________________________ Notary Public Endorsement by County Auditor: Upon presentation of this instrument, the County Auditor shall indorse it, return it to the grantee or his representative, and provide a copy of the indorsed instrument to the grantor or his representative, evidencing delivery to the County Auditor. County Auditor: ___________________________________ Date: ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com