REAL ESTATE TRANSFER - DECLARATION OF VALUE Please read the filing instructions BEFORE completing this form. To enter information, use the "Tab" key to move to each field. PART I - TO BE COMPLETED BY BUYER, SELLER, OR AGENT (Please Type or Print Legibly) Social Security No. SELLER Name (or Federal I.D. No.) Address Number and Street or Rural Route BUYER City, Town or Post Office State Zip State Zip Social Security No. (or Federal I.D. No.) Name Address Number and Street or Rural Route City, Town or Post Office Address of Property Conveyed Number and Street or Rural Route City, Town or Post Office State Zip Legal Description of Property If this is a sale of AGRICULTURAL LAND to one of the following persons or entities, please check ( x ) the appropriate box. Corporation Trust Alien Non-Resident Alien Limited Partnership Declaration of Value Statement 1. 2. 3. 4. Total Amount Paid Amount Paid for Personal Property (See Instructions) Amount Paid for Real Property Only (1 minus 2) Contract Sale Information - Please See Instructions Down Payment $ Length of Contract $ $ $ Interest Rate % Monthly Payment years Balloon Payment Date (if applicable) SALES CONDITIONS: Check (X) ALL of the following that apply to this sale Corporate Merger or Reorganization Exchange for Other Property ("Trade") Sale to/by Exempt Organization Sale Between Family Members (See Instructions) Fulfillment of Prior Year Contract Transfer of Partial Interest Other (Explain) Purchase of Adjoining Land Auction Sale Quit Claim Deed I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART 1 OF THIS FORM IS TRUE AND CORRECT. Telephone Number Signature: ( ) (Buyer OR Seller OR Agent) PART II - TO BE COMPLETED BY RECORDER Book (or instrument identification) Date of Instrument Date of Recording Contract Page (or instrument identification) City or Township Deed County Real Estate Transfer Tax Paid PART III - TO BE COMPLETED BY ASSESSOR (1) Urban Classification of Property AGRICULTURAL REALTY (1) Rural COMMERCIAL RESIDENTIAL (1) Dwelling Unimproved Farm Business (3) Apartment (1) Single-Family Dwlg. (2) Improved Farm (2) (2) Office (4) Other (2) Two-Family Dwlg. INDUSTRIAL (1) Story Height Lot & Bldgs. Age of Dwelling SALES CONDITIONS Lot Assessed As Unplatted Land Sale of Portion of Property ("Split") A B C D Partial Assessment E Other (Explain Below) F (For Dept. of Revenue Use Only) NOTE: ASSESSED VALUE MUST BE AS OF JANUARY 1, OF THE YEAR IN WHICH THE SALE OCCURRED Assessment Data LAND BLDGS. $ SALES RATIO TOTAL $ % $ Assessor Comments N APPROVED BY IDR O P DEPARTMENT OF REVENUE American LegalNet, Inc. www.FormsWorkflow.com