Recorder P.O. Box 751 Riverside, CA 92502-0751 (951) 486-7000 LARRY W. WARD COUNTY OF RIVERSIDE ASSESSOR-COUNTY CLERK-RECORDER Website: www.riversideacr.com DOCUMENTARY TRANSFER TAX AFFIDAVIT 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 UNDER SECTION 5 OF ORDINANCE 516 OF THE COUNTY OF RIVERSIDE 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. 2. 3. 4. 5. ___ Section 11911. ___ Section 11911. ___ Section 11921. ___ Section 11922. ___ Section 11925. 6. ___ Section 11926. 7. ___ Section 11926. 8. ___ Section 11927. 9. ___ Section 11930. The document is a lease for a term of less than thirty-five (35) years (including options). The easement is not perpetual, permanent, or for life. The instrument was given to secure a debt. The conveyance is to a governmental entity or political subdivision. The transfer is between individuals and a legal entity, or between legal entities, and does not change the proportional interests held. The instrument is from a trustor to a beneficiary, in lieu of foreclosure, and no additional consideration was paid. The grantee 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. 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. Also, 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 Form 709 (Federal Gift Tax Return) with the Internal Revenue Service. 10. ___ Section 11930. The conveyance is to the grantor’s revocable living trust. 11. ___ Other (Include explanation and 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 Printed Name of Affiant ______________________________________________ Name of Firm (if applicable) _____________________________________________________ Address of Affiant _____________________________________________________ Telephone Number of Affiant (including area code) This form is subject to the California Public Records Act (Government Code 6250 et. seq.) For Recorder’s Use: Affix PCOR Label Here ACR 521P-AS4EX0 (Rev. 11/2010) Available in Alternative Formats American LegalNet, Inc. www.FormsWorkFlow.com