CTRL # CO Y Y Y Y MM # # # # # REAL ESTATE TRANSFER - DECLARATION OF VALUE Please read the instructions comprised in form 57-011 before completing and filing this form. Part I - TO BE COMPLETED BY BUYER, SELLER OR AGENT Date of Instrument (MMDDYYYY) Enter the number matching your selection in the box at the end of the line: Deed (1) Contract (2) Seller: Seller Address: State: Buyer: Buyer Address: State: Address of Property Conveyed: City: Legal Description: Enter the number corresponding to your selection in the box at the end of the line, if applicable. Type of Sale: Sale between related parties/family (1); Sale of partial interest (2); Trade (3); Quit Claim Deed (4); Auction (5) Was this a sale of agricultural land to: Corporation (1); Trust (2); Alien (3); Non-resident Alien (4); Limited Partnership (5) Phone Number: City: ZIP: email: Phone Number: City: ZIP: email: State: ZIP: DECLARATION OF VALUE STATEMENT 1. Total Amount Paid .................................................................... 2. Amount Paid for Personal Property .......................................... 3. Amount Paid for Real Property ................................................. , , , , , , .00 .00 .00 I hereby declare that the information contained in Part I of this form is true and correct. Printed Name: Signature: Effective On or Before 07/01/16 Phone Number: Buyer Page 1 or Seller American LegalNet, Inc. www.FormsWorkFlow.com or Agent or Attorney 57-006a (03/15/16) Real Estate Transfer ­ Declaration of Value, Page 2 Part II - TO BE COMPLETED BY THE ASSESSOR Assessed values must be as of January 1 of the year in which the sale occurred. SECTION A: SINGLE CLASSIFICATION Primary Classification: Residential (4); Commercial (5); Industrial (2); Agricultural (1); Multi-residential (7) City/Township: Primary Parcel Number: Class Res Com Ind Ag MultiRes Occupancy: Year Built: Building Dwelling Land , . , . , . , . , . .00 .00 .00 .00 .00 , , , , , , , , , , .00 .00 .00 .00 .00 , , .00 , , , , , , .00 .00 .00 Subtotal .......................... SECTION B: DUAL CLASSIFICATION Primary Classification: City/Township: Primary Parcel Number: Class Com Ind MultiRes Commercial (5); Industrial (2); Multi-residential (7) Occupancy: Year Built: Land Building Dwelling , . , . , . .00 .00 .00 , , , , , , .00 .00 .00 , , , , .00 .00 Subtotal.................................................................... Total: Add Subtotal amounts from Sections A and B .................... Enter amount from line 3, page 1 ............................................... , , , , , . NUTC Jurisdiction .00 .00 % Ratio: Divide Total amount by the amount on line 3, page 1 ........................... : Comments: Effective on or before 07/01/16 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 57-006b (03/15/16) Real Estate Transfer ­ Declaration of Value Instructions Visit the Department website at https://tax.iowa.gov for more information. FILING INSTRUCTIONS: Iowa law requires that a "Declaration of Value" statement reflecting the full consideration paid in certain nonexempt real estate conveyances be submitted to the county recorder at the time a deed, contract, instrument, or other writing is presented for recording. The blank area at the top of page 1 of form 57-006, Real Estate Transfer- Declaration of Value, is for use by the county recorder. In this area the recorder will provide the following information: Date of Recording, Book and Page Number or Instrument Number, County, or Real Estate Transfer Tax. Part I of the form is the prescribed "Declaration of Value" statement that must be completed by the buyer or seller or either's agent for nonexempt transactions. Part II of the form is to be completed only by the assessor. IMPORTANT: This form does not have to be completed for any document presented for recording which clearly indicates on such document that it is an exempt transaction. Refer to Iowa Administrative Code 70179.5. If the transaction is exempt, but the reason for exemption is not stated on the actual document presented for recording, Part I of this form must be completed. If this form is not completed accurately and completely for nonexempt transactions by the buyer or seller or either's agent, the county recorder is required by law to refuse to record the contract, deed or other instrument conveying the affected property. TYPE OF SALE: Enter the number corresponding to your selection in the box at the end of the line on page 1, if applicable. For purposes of indicating a "Sale Between Family Members" only the following relationships are to be considered: Mother Daughter Sister Sister-in-law Stepsister Mother-in-law Daughter-in-law Niece Foster child Foster parent Foster brother Foster sister Father Son Brother Brother-in-law Stepbrother Father-in-law Son-in-law Nephew Grandson Granddaughter Grandfather Grandmother Stepmother Stepfather Stepson Stepdaughter Uncle Aunt DECLARATION OF VALUE STATEMENT: Line 1. Total Amount Paid: Enter the entire and full purchase price of the property transferred, including down payment. Note: Reporting of personal property should conform to the transfer document and any related income tax filings. Line 2. Amount Paid for Personal Property: Enter the amount of the purchase price that was paid for personal property. For residential sales, personal property includes items that are not attached ("built in") to the home that are normally removed by the owner, when he or she vacates. This includes, but is not limited to, items such as washers, dryers, drapes, stoves, refrigerators, and portable dishwashers. Personal property for commercial or industrial sales includes inventories, as well as equipment and fixtures classified and assessed as personal property. Reporting of personal property should conform to the transfer document and any related income tax filings. Line 3. Amount Paid for Real Property Only: Subtract Line 2 from Line 1 and enter the difference here. Effective on or before 07/01/16 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 57-011a (03/15/16) Real Estate Transfer ­ Declaration of Value Instructions, Page 2 IMPORTANT: If this transaction is exempt from the transfer tax, you may not be required to complete this form. Exemption numbers 1, 6, 14, or 15 require a Declaration of Value form to be completed. Exceptions Iowa Code 428A.2 merger, consolidation, or reorganization of a limited 1. (DOV required) Any executory contract for the liability company under the