STATEMENT OF CHANGE IN BENEFICIAL INTEREST APN: ___________________________ ROLL: ___________________________ INSTRUCTIONS: COMPLETE A SEPARATE FORM FOR EACH PARCEL FOR WHICH AN ASSESSOR’S PARCEL NUMBER HAS BEEN ASSIGNED. ANSWER EACH QUESTION AND UPON COMPLETION OF FORM SIGN AND SEND ORIGINAL TO: COUNTY OF MARIN, OFFICE OF THE ASSESSOR-RECORDER JOAN C. THAYER, ASSESSOR-RECORDER P.O. BOX C, CIVIC CENTER BRANCH SAN RAFAEL, CA 94913 • ___________________________ • ___________________________ • DOD: REF#: TT: TRSF: ENRL: MAC: ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ Areas Inside Shaded Borders For Assessor-Recorder’s Use Only A. Decedent’s Name: __________________________________________________ Date of Death:_________ Probate File #:________ County: __________ 1. Assessor’s Parcel Number(s): _____________________________________ 2. Property Address: _______________________________________________ B. Disposition of the real property will be: (check one) c Intestate succession. c Affidavit of death. c Distribution of community property to surviving spouse. c Decree of distribution pursuant to will. c Action of trustee pursuant to terms of a trust. c Other (explain on reverse side) C. This property has been sold / will be sold prior to distribution. c Yes c No D. Name and mailing address to be used for future tax statements: Continue to next page Civic Center • P. O. Box C • San Rafael, CA 94913 • 415/499-7231 • FAX 415/499-6255 American LegalNet, Inc. www.FormsWorkflow.com ∂ APN: ______________________ DOD: _________________ DEED REF# __________________ 1. Please supply all anticipated successor(s) in interest, relationship to decedent and percentage of interest to be acquired. If the property is for sale or has sold, who is entitled to the proceeds and what percentage are they to receive? Successor (beneficiary) Relationship % Interest 2. Please provide any additional information regarding the question above, or other information, that may help the Assessor-Recorder understand the nature of the transfer. (Attach additional sheets if necessary) CERTIFICATION I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing and all information hereon, including accompanying statements or documents, is true, correct and complete to the best of my knowledge and belief. This declaration is binding on each and every coowner and/or partner. SIGNATURE OF ADMINISTRATOR/EXECUTOR/TRUSTEE/ATTORNEY TITLE PRINT NAME DATE ADDRES S TELEPHONE NUMBER (8 a.m. – 5 p.m.) ( ) The Assessor may contact you for additional information if necessary. If you have any questions, please call (415) 499-7360 between 8 a.m. and 3 p.m. (PST) Monday through Friday. 125-450 (081602) American LegalNet, Inc. www.FormsWorkflow.com