COUNTY OF EL DORADO RECORDER CLERK - REGISTRAR OF VOTERS - VETERANS AFFAIRS William E. Schultz _______ Recorder-Clerk Commissioner of Civil Marriages 360 Fair Lane Placerville CA 95667 www.edcgov.us/countyclerk/ Phone: 530.621.5490 Jane Kohlstedt Assistant Recorder-Clerk Registrar of Voters 2850 Fairlane Court PO Box 678001 Placerville CA 95667 www.edcgov.us/elections/ Phone: 530.621.7480 Fax: 530.626.5514 Linda Webster Assistant Registrar of Voters Veterans Affairs Office 130 Placerville Drive, Placerville CA 95667 www.edcgov.us/veterans/ Phone: 530.621.5893 William E. Schultz Veterans Affairs Interim Dept. Head Ed Swanson Veterans Service Officer TRANSFER TAX AFFIDAVIT DOCUMENT SERIES NUMBER: _________________________________________________________ I CLAIM THAT THE DOCUMENT PRESENTED WITH THIS AFFIDAVIT IS EXEMPT FROM DOCUMENTARY TRANSFER TAX. 1. LOCATION OF PROPERTY Address: _________________________________________________________________________________________ _________________________________________________________________________________________________ 2. IS THIS A FORECLOSURE OR A TRUSTEE SALE TO FORECLOSING BENEFICIARY? 3. IS THIS A LEASE WITH A REMAINING TERM EQUAL OR GREATER THAN 35 YEARS: Yes (If yes provide copy of terms or summary) No (If no, proceed to #4) 4. IS THIS A GIFT IN WHOLE OR IN PART? Yes No If yes, enter the fair market value here $ ____________________ Name of Transferor/Donor: _________________________________________________________________________ Name of Transferee/Donee: _________________________________________________________________________ Please be aware that certain gifts may trigger a Federal Gift Tax. In such cases the Transferor (Donor) may be required to file a Federal Gift Tax Return with the Internal Revenue Service. Please also be aware that information stated on this document may be given to and, used by governmental agencies, including the Internal Revenue Service. I, as the Transferor (donor) named above declare under penalty of perjury, that I have read paragraph #4 and acknowledge that a Federal Gift Tax may be triggered. If a Trust Deed (loan) follows this document I guarantee that no payoff of an existing loan has been made nor, am I receiving value of any kind. Grantor: ________________________________________, 5. DO YOU CONTEND THAT NO TRANSFER TAX IS DUE FOR A REASON NOT EXPLAINED ABOVE? Yes No (If no proceed to #6) If yes, explain fully: (1) The nature of this transaction and the reason you contend no tax is due (2) The reason you contend no transfer tax is due. (Use additional papers if necessary and attach copies of records or documents. (i.e. Tax returns, Entity Formation Documents that support claim 6.) Yes No (If no proceed to section #3) 6. Complete the following and calculate the tax below: a. Consideration Paid Documentary Transfer Tax is $.55 per $500.00 TAX DUE: 7. CONTACT INFORMATION $ _________________ $ _________________ a. NAME OF CONTACT PERSON: _______________________________________________________________________ b. TELEPHONE NUMBER: _______________________________________________________________________ c. MAILING ADDRESS: _______________________________________________________________________ I DECLARE OR AFFIRM UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. SIGNATURE OF NEW OWNER/DATE OF EXECUTION: _______________________________________________________________ WARNING ANY PERSON WHO MAKES ANY MATERIAL MISREPRESENTATION OF FACT FOR THE PURPOSE OF AVOIDING ALL OR ANY PART OF THE DOCUMENTARY TRANSFER TAX IS GUILTY OF A MISDEMEANOR. American LegalNet, Inc. www.FormsWorkFlow.com