Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return to the Department of Revenue Services (DRS) is a 336 ne of not more than $5,000, or imprisonment for not more than 336 ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge. Name of person signing the return (type or print) Signature DateName of grantor222s representative (type or print) Connecticut juris number if applicable Telephone number Indicate who is signing this return: Grantor Grantor222s attorney Grantor222s authorized agent Department of Revenue ServicesState of ConnecticutPO Box 5035Hartford CT 06102-5035OP236 0417W 01 9999 OP-236Connecticut Real Estate Conveyance Tax Return(Rev. 04/17)Complete Form OP-236 in blue or black ink only. -FEINSSN4. Grantor/seller #1 (last name, 336 rst name, middle initial) Taxpayer Identi336 cation Number Grantor/seller address (street and number) after conveyance City/town State ZIP code FEINSSN10. Grantee/buyer (last name, 336 rst name, middle initial) Taxpayer Identi336 cation Number Grantee/buyer address (street and number) after conveyance City/town State ZIP code1. Town 2. Location of property conveyed (number and street) Amended return3. Are there more than two grantors/sellers? Yes If Yes, attach OP-236 Schedule A - Grantors, Supplemental Information for Real Estate Conveyance Tax Return. FEINSSN5. Grantor/seller #2 (last name, 336 rst name, middle initial) Taxpayer Identi336 cation Number Grantor/seller address (street and number) after conveyance City/town State ZIP code9. Is there more than one grantee/buyer or, is the grantee a partnership, S corporation, LLC, estate, or trust? YesIf Yes, attach OP-236 Schedule B - Grantees, Supplemental Information for Real Estate Conveyance Tax Return. 15. Consideration for unimproved land x 0.0075 = 16. Total consideration for residential dwelling 16a. Portion of Line 16 that is $800,000 or less x 0.0075 = 16b. Portion of Line 16 that exceeds $800,000 x 0.0125 = 17. Residential property other than residential dwelling x 0.0075 = 18. Nonresidential property other than unimproved land x 0.0125 = 19. Property conveyed by a delinquent mortgagor x 0.0075 = 20. Total State of Connecticut tax due: Add Lines 15, 16a through 19.Computation of Tax - Enter consideration for conveyance on the appropriate line. See Instructions.11. Date conveyed (MM - DD - YYYY) 12. Date recorded (MM - DD - YYYY) 13. Type of instrument: Warranty Quitclaim Easement Other14. The grantor claims no tax is due because (See instructions.): Conveyance was for no consideration or consideration was less than $2,000. Conveyance is exempt under Conn. Gen. Stat. 24712-498. Enter exemption code: If exemption code is 01 or 09, enter citation or docket number: - - Vol. Pg. For Town Clerk Use OnlyTown Code Land Record 6. Is the grantor a partnership, S corporation, LLC, estate, or trust? Yes If Yes, attach OP-236 Schedule A - Grantors 7. Was more than one deed 336 led with this conveyance? Yes8. If this conveyance is for no consideration or less than Federal only State only Both fed. & state Noneadequate consideration, which gift tax returns will be 336 led? American LegalNet, Inc. www.FormsWorkFlow.com OP-236Connecticut Real Estate Conveyance Tax Return(Rev. 04/17) Town Clerk Copy 4. Grantor/seller #1 (last name, 336 rst name, middle initial) Grantor/seller address (street and number) after conveyance City/town State ZIP code 10. Grantee/buyer (last name, 336 rst name, middle initial) Grantee/buyer address (street and number) after conveyance City/town State ZIP code3. Are there more than two grantors/sellers? Yes 5. Grantor/seller #2 (last name, 336 rst name, middle initial) Grantor/seller address (street and number) after conveyance City/town State ZIP code 15. Consideration for unimproved land x 0.0075 = 16. Total consideration for residential dwelling 16a. Portion of Line 16 that is $800,000 or less x 0.0075 = 16b. Portion of Line 16 that exceeds $800,000 x 0.0125 = 17. Residential property other than residential dwelling x 0.0075 = 18. Nonresidential property other than unimproved land x 0.0125 = 19. Property conveyed by a delinquent mortgagor x 0.0075 = 20. Total State of Connecticut tax due: Add Lines 15, 16a through 19.Computation of Tax - Enter consideration for conveyance on the appropriate line. See Instructions. - --1. Town 2. Location of property conveyed (number and street) Amended return Vol. Pg.For Town Clerk Use OnlyTown Code Land Record 9. Is there more than one grantee/buyer or, is the grantee a partnership, S corporation, LLC, estate, or trust? Yes 11. Date conveyed (MM - DD - YYYY) 12. Date recorded (MM - DD - YYYY) 13. Type of instrument: Warranty Quitclaim Easement Other 14. The grantor claims no tax is due because (See instructions.): Conveyance was for no consideration or consideration was less than $2,000. Conveyance is exempt under Conn. Gen. Stat. 24712-498. Enter exemption code: If exemption code is 01 or 09, enter citation or docket number: 6. Is the grantor a partnership, S corporation, LLC, estate, or trust? Yes 7. Was more than one deed 336 led with this conveyance? Yes8. If this conveyance is for no consideration or less than Federal only State only Both fed. & state Noneadequate consideration, which gift tax returns will be 336 led? American LegalNet, Inc. www.FormsWorkFlow.com Last name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP code SSN FEIN SSN FEIN SSN FEIN SSN FEIN SSN FEIN SSN FEIN Use OP-236 Schedule A to provide the required information if there are additional grantors/sellers. If the grantor is a partnership,S corporation, limited liability company (LLC), estate, or trust, enter the name, address, and taxpayer identi336 cation number of the partners, shareholders, members, or bene336 ciaries. If a partner, shareholder, member or bene336 ciary of the grantor is an LLC or a quali336 ed subchapter S corporation (QSS), enter the name of such entity, its address and tax identi336 cation number. Do not combine grantors/sellers andgrantee/buyers on the same schedule. Town Was the transaction completed on one deed? Date conveyed Yes No Location of property conveyed Date recorded Name of grantor as shown on the deed m m d d y y y y / / m m d d y y y y / / SSN FEINDepartment of Revenue ServicesState of ConnecticutOP236A 1016W 01 9999 OP-236 Schedule A - GrantorsSupplemental Information for ConnecticutReal Estate Conveyance Tax Return(Rev. 10/16) American LegalNet, Inc. www.FormsWorkFlow.com Last name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town State ZIP codeLast name, 336 rst name, middle initial Taxpayer identi336 cation number Address after conveyance City or town Stat