BARBARA J. LEVEY COUNTY OF MERCED ASSESSOR-CLERK-RECORDER DOCUMENTARY TRANSFER TAX AFFIDAVIT WARNING RECORDER 2222 "M" Street Merced, CA 95340 (209) 385-7627 (209) 725-3956 Fax www.co.merced.ca.us 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 UNDER SECTION 5.20 OF ORDINANCE 1929 OF THE COUNTY OF MERCED AND IS SUBJECT TO PROSECUTION FOR SUCH OFFENSE. ASSESSOR'S PARCEL NO. _____--_____--_____ Property Address: ___________________________ I declare that the documentary transfer tax for this transaction is: $___________________. If this transaction is exempt from Documentary Transfer Tax, the reason must be identified below. I CLAIM THAT THIS TRANSACTION IS EXEMPT FROM DOCUMENTARY TRANSFER TAX BECAUSE: (The Sections listed below are taken from the Revenue and Taxation Code). Please check one or explain in "Other". 1.____ Section 11911 The consideration or value of the property, exclusive of any liens and encumbrances is $100.00 or less and there is no additional consideration received by the grantor. 2.____ Section 11921 The conveyance was given to secure a debt, provided the proportional ownership will revert back to the original holding within one month of recording The conveyance is to a governmental entity or political subdivision. Conveyance under bankruptcy Federal Case No.___________________ Transfer by order of the Securities and Exchange Commission Case No._________________ The transfer is between individuals and a legal entity or partnership, or between legal entities and does not change the proportional interests held. 3.____ Section 11922 4. ____Section 11923 5.____Section 11924 6. ____Section 11925 IS THIS A TRANSFER BETWEEN LEGAL ENTITIES? Yes NO IF YES, TRANSFERS INVOLVING LEGAL ENTITIES MUST PROVIDE, PREFERRABLY ONE (1) WEEK IN ADVANCE, APPLICABLE DOCUMENTATION. SOME EXAMPLES ARE LISTED BELOW. THIS TYPE OF TRANSACTION MAY REQUIRE 1-3 BUSINESS DAYS TO REVIEW. Entity ownership documentation is required if you are a: Corporation ­A copy of the Articles of Incorporation amendments and any other documents showing the shares issued and share ownership; or LLC-A copy of the Operating Agreement, amendments, and any other documentation showing the partners and ownership/percentage; or Partnership- A copy of the Partnership Agreement, Amendments and any other documents showing the partners and ownership percentage. For Recorder's Use: MCR 11911 (Rev. 09/16) American LegalNet, Inc. www.FormsWorkFlow.com 7. ____ Section 11926 The conveyance is to a grantee who is the foreclosing beneficiary and the consideration paid by the foreclosing beneficiary does not exceed the unpaid debt. The conveyance relates to a dissolution of marriage or legal separation. (A spouse must sign a written recital in order to claim this exemption. This form may be used for that purpose.) 8. ____ Section 11927 9. ____ Section 11930 The conveyance is an inter vivos gift* or a transfer by death. *Please be aware that information stated on this document may be given to and used by governmental agencies, including the Internal Revenue Service. Additionally, certain gifts in excess of the annual Federal gift tax exemption may trigger a Federal Gift Tax. In such cases, the Transferor (donor/grantor) may be required to file Form709 (Federal Gift Tax Return) with the Internal Revenue Service. 10. ____The easement is not perpetual, permanent, or for life. 11.____The document is a lease for a term of less than (35) years (including written options.) 12.____Other (Include explanation and legal authority) __________________________________________________ ______________________________________________________________________________________________ I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Executed this ________day of ________________________, 20_______ at _________________________________ City, State ________________________________________ Signature of Affiant/ Authorized Representative _____________________________________________ Printed Name of Affiant/ Authorized Representative ____________________________________________ ________________________________________________ Name of Firm (if applicable) Address of Affiant (including City, State, and Zip Code) ________________________________________________ Telephone Number of Affiant (including area code) This form is subject to the California Public Records Act (Government Code 6250 et. seq.) American LegalNet, Inc. www.FormsWorkFlow.com