County of San Mateo TRANSFER TAX AFFIDAVIT Per San Mateo County Ordinance Code 2.93.050 NOTICE: Any material misrepresentation of fact in this affidavit is a misdemeanor under section 2.93.120 of the San Mateo County real property tax code. Any person who makes such a representation is subject to prosecution for such offense. The Assessor-Clerk-Recorder reserves the right to report potentially fraudulent recordings to the District Attorney's Real Estate Fraud Unit. DTT AFFIDAVIT This form must accompany any document that requires a Documentary Transfer Tax declaration, including but not limited to; Agreement for Sale; Assignment of Lease; Deed in Lieu of Foreclosure; Easement; Grant Deed; Land Contract; Lease; Memorandum of Lease; 1. LOCATION OF PROPERTY: Assessor's Parcel Number: Street Address: 2. IS THIS A FORECLOSURE OR TRUSTEE SALE? a. Is the transferee the Beneficiary or Mortgagee? b. Please provide. Name of Trustee: Date of original Deed of Trust: 3. IS THIS A LEASE? -- -- City: Document To Be Recorded: Yes Yes No (If yes, complete this section.) No Yes No (If yes or no, complete this section.) a. Is remaining term of lease, including renewal options, greater than 35 years? b. If NO, submit a copy of the lease, or summary, or terms. c. If YES, enter the value of the lease interest on line 9a. (For tax calculations.) 4. IS THIS A GIFT IN WHOLE OR IN PART? Name of the Donor: Name of the Donee: Yes No Yes No (If yes, give a complete explanation.) Please be aware that certain gifts in excess of $13,000 per calendar year may trigger a Federal Gift Tax. In such cases, the Transferor/Donor may be required to fill out a Form 709 (Federal Gift Tax Return) with the Internal Revenue Service. Please also be aware that the information stated on this document may be given to and used by governmental agencies, including the Internal Revenue Service. I, as the Transferor/Donor declare under penalty of perjury that I have read the above paragraph and acknowledge that a Federal Gift Tax may be triggered. 5. ( Print Donor Name: ) Donor Phone: Signature of Donor: SIGNATURE ON REVERSE STILL REQUIRED. Yes No ARE YOU ADDING OR REMOVING A CO-OWNER FOR REFINANCING PURPOSES? If yes, initial to the right to indicate your agreement with the statement below and sign on reverse. Initial here: The proportional ownership interest will revert back to its original holding within one (1) month from the date of recording; otherwise I will pay the applicable transfer tax. Continued on Reverse Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION. TRANSFER TAX AFFIDAVIT, pg. 2 6. ARE YOU MOVING TITLE INTO OR OUT OF A TRUST? a. Name of Trust: c. Name of Trustor(s): d. Name(s) of Currently Active Trustee(s): e. If this transaction changes who is on title or the proportional interest of how title is held, further explanation is required and may require additional time to review. Attach additional page(s) if necessary. Yes No / Into Out of / Revocable Irrevocable b. Date of Trust: 7. DO YOU CONTEND THAT NO TRANSFER TAX IS DUE FOR A REASON NOT EXPLAINED IN #1-6? a. The nature of the transaction is: b. The reason (exemption) you claim no tax is due: 8. (If yes, give a complete explanation.) Yes No IS THIS A TRANSFER BETWEEN LEGAL ENTITIES? Yes No IF YES, TRANSFERS INVOLVING LEGAL ENTITIES MUST PR0VIDE, PREFERRABLY ONE (1) WEEK IN ADVANCE, APPLICABLE DOCUMENTATION. SOME EXAMPLES ARE LISTED BELOW. THIS TYPE OF TRANSACTION WILL REQUIRE 1-3 BUSINESS DAYS TO REVIEW. Entity ownership documentation is required if you are a: Corporation--A LLC--A Partnership-- 9. copy of the Articles of Incorporation amendments and any other documents showing the shares issued and share ownership; or copy of the Operating Agreement, amendments, and any other documentation showing the partners and ownership \percentage; or A copy of the Partner Agreement, amendments and any other documents showing the partners and ownership percentage. For all legal entities, provide the names of individuals and specific percentages held by each individual prior to and following the transfer. TAXABLE TRANSACTIONS: Complete the following and calculate the tax below. Tax is calculated as $0.55 per $500 of line 9D. Example, $100,000 value/$500 increments = 200. 200 increments x $0.55 = $110 in tax due. You may also use $1.10 A) Consideration paid or value. $ B) Full cash value. Less liens. C) If less liens, loan amount assumed. $ D) Total consideration or value less liens. (Line A minus line C.) $ E) Tax due. $ I DECLARE OR AFFIRM UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Are you the Transferee, Transferor, Both, or Representative with full knowledge of foregoing. Signature still required. Signature of Transferee: Address of Transferee: Print Name: Phone Number of Transferee: ( ) Signature of Transferor: Address of Transferor: Place of Execution: (City, County, State where executed.) REC-SMC-012011-REV_2 (02/2011) Print Name Phone Number of Transferor: Date of Execution Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ( )