Townships: East Hampton Riverhead Shelter Island Southampton Southold Peconic Bay Region Community Preservation Fund 03 06 07 09 10 Proceeds of this transfer tax are disbursed to the Townships in which the transaction takes place for its acquisition of land, development rights, and other interests in property for conservation purposes. Please print or type. Schedule A Information Relating to Conveyance Individual Corporation Partnership Name (individual; last, first, middle initial) Social Security Number Mailing address Grantor Social Security Number City Other Grantee State ZIP code Federal employer idenl. number Name (individual; last, first, middle initial) Social Security Number Mailing address Social Security Number Individual Corporation Partnership City Other State ZIP code Federal employer idenl. number Location and description of property conveyed Tax map designation Dist Section Block Address Village Town Lot Type of property conveyed (check applicable box) Date of conveyance Improved Vacant land month day Dual Towns: year Condition of conveyance (check all that apply) a. - Conveyance of fee interest b. - Acquisition of a controlling interest (state percentage acquired ______________ %) c. - Transfer of a controlling interest (state percentage transferred ____________ %) d. - Conveyance to cooperative housing corporation e. - Conveyance pursuant to or in lieu of foreclosure or enforcement of security f. - Conveyance which consists of a mere change of identity or form of ownership or organization g. - Conveyance for which credit (or tax previously paid will be claimed h. - Conveyance of cooperative apartment(s) i. - Syndication j. - Conveyance of air rights or development rights interest k. - Contract assignment l. - Option assignment or surrender m. - Leasehold assignment or surrender n. Leasehold grant o. - Conveyance of an easement p. Conveyance for which exemption is claimed (complete Schedule B. Part II) q. - Conveyance of property partly within and partly without the state r. - Other (describe) ____________________ Schedule B - Community Preservation Fund Part I - Computation of Tax Due 1. Enter amount of consideration for the conveyance (from line 1 TP584 Schedule B) 2. Allowance (see below) 3. Taxable consideration (subtract line 2 from line 1) 4. 2% Community Preservation Fund (of line 3) make certified check payable to SUFFOLK COUNTY CLERK 5. Property not subject to CPF Tax (See Schedule C) For recording officer's use Amount received Date received 1 2 3 4 5 Transaction number Allowance: East Hampton Shelter Island Southampton $250,000.00 Improved $250,000.00 Improved $250,000.00 Improved $100,000.00 Vacant Land (Unimproved) $100,000.00 Vacant Land (Unimproved) $100,000.00 Vacant Land (Unimproved) Riverhead Southold $150,000.00 Improved $150,000.00 Improved $ 75,000.00 Vacant Land (Unimproved) $ 75,000.00 Vacant Land (Unimproved) 12-0213.. 09/01cg American LegalNet, Inc. www.FormsWorkflow.com Schedule C - (continued) Part II - Explanation of Exemption Claimed in Part I, line 1 (check any boxes that apply) The conveyance of real property is exempt from the real estate transfer tax for the following reason: a. Conveyance is to the United Nations, the United States of America, the state of New York or any of their instrumentalities, agencies or political subdivisions (or any public corporation, including a public corporation created pursuant to agreement or compact with another state or Canada) b. Conveyance is to secure a debt or other obligation c. Conveyance is without additional consideration to confirm, correct, modify or supplement a prior conveyance d. Conveyance of real property is without consideration and not in connection with a sale, including conveyances conveying realty as bona fide gifts e. Conveyance is given in connection with a tax sale f. Conveyance is mere change of identity or form of ownership or organization where there is no change in beneficial ownership. (This exemption cannot be claimed for a conveyance to a cooperative housing corporation of real property comprising the cooperative dwelling or dwellings.) g. Conveyance consists of deed of partition h. Conveyance is given pursuant to the federal bankruptcy act i. Conveyance consists of the execution of a contract to sell real property without the use or occupancy of such property or the granting of an option to purchase real property without the use or occupancy of such property j. Conveyance or real property which is subject to restrictions which prohibit the use of the entire property for any purposes except agriculture, recreation or conservation, pursuant to Section 1449-ee (2) (j) or (k) of Article 31-D of the Tax Law. (See required Town approval, below) k. Conveyance of real property for open space, parks, or historic preservation purposes to any not-for-profit tax exempt corporation operated for conservation, environmental, or historic preservation purposes. l. Other list explanations in space below (Grandfather/Contract) m. Conveyance of real property as a primary residence where the grantee is a first-time homebuyer (attached approved application) n. Conveyance of real property to a tax exempt, not-for-profit corporation for the purpose of providing affordable housing. o. The conveyance is approved for an exemption from the Community Preservation Transfer Tax, under Section 1449-ee of Article 31-D of the Tax law. (See j in Schedule C) _______________________________________________________________ Town Attorney or other designated official Penalties and Interest Penalties Interest Any grantor or grantee failing to file a return or to pay any tax within the time required shall be subject to a penalty of 10% of the amount of tax due plus an interest penalty of 2% of such amount of each month of delay or fraction thereof after the expiration of the first month after such return was required to be filed or the tax became due. However, the interest penalty shall not exceed 25% in the aggregate. Signature (both the grantor(s) Daily compounded interest will be charged on the amount of the tax due not paid within the time required. and grantee(s) must sign). The undersigned certify that the above return, including any certification, schedule or attachment, is to the best of his/her knowledge, true and complete. Grantor Grantee Grantor Grantee 12-0213:: 09/01cg American LegalNet, Inc. www.FormsWorkflow.com