DECLARATION_OF_DOCUMENTARY_TRANSFER_TAX The undersigned, having knowledge of the transaction, does hereby disclose the following information to the Recorder of Placer County for the purpose of determining transfer tax on the documents submitted for recording in connection with this transaction. APN:______________________________________ STREET ADDRESS:_______________________________________________ TYPE OF TRANSACTION:_______________________________________________________________ COMPUTATION INFORMATION Sale Price of Property Value if other than sale Encumbrances or liens Amount tax based on Tax ($.55 per $500. Or portion thereof) Value obtained by appraisal $_______________________________________________ $_______________________________________________ $_______________________________________________ $_______________________________________________ $_______________________________________________ YES_______________ NO__________________ REASON FOR NO TAX DUE: _____Gift Deed _____Deed to or by a trustee not pursuant to a sale. _____Deed to confirm title already vested in grantee, to correct a flaw in title. _____Deed given by an executor in accordance with the terms of the will. _____Ordinary leases of real property for less than 35 years. _____Deed to a trustee for the benefit of creditors. _____Deed from an agent to this principal conveying real estate purchases for and with funds of the principal. _____Conveyance by a corporation in liquidation or in dissolution to its shareholders made solely for the cancellation and retirement capital stock. _____Conveyance from a corporation in liquidation to a partnership wherein the corporate shareholders are the only partners of the partnership and hold proportional interests in each entity. _____Conveyance is in dissolution of marriage by one spouse to the other. _____Conveyance from one spouse to the other as sole and separate property. _____Other: (explain below) ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________________ I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNED:________________________________________________________ DATE:____________________________________ FIRM NAME:____________________________________________________ PLACE:___________________________________ NOTE: This information is not made a part of the recorded document but is made available to the Internal Revenue Service and other taxing agencies. American LegalNet, Inc. www.FormsWorkFlow.com