Real Property Conveyance Fee Statement of Value and Receipt If exempt by Ohio Revised Code section 319.54(G)(3), use form DTE 100(ex) FOR COUNTY AUDITOR'S USE ONLY Type Instrument Tax list year County number Tax Dist number Date DTE 100 Rev 1/14 2016 August Property located in ____________________________________________________________ taxing district Name on tax duplicate ____________________________________________ Tax duplicate year __________ Permanent Parcel Number _______________________________________ Map book _____ Page ______ Description ___________________________________________________ Platted Unplatted Auditor's comments: Split New plat New improvements Partial value C.A.U.V. Building removed Other __________________________________ Number No. of Parcels DTE Code No. Neigh. Code No. of Acres Land Value Bldg. Value Total Value GRANTEE OR REPRESENTATIVE MUST COMPLETE ALL QUESTIONS IN THIS SECTION TYPE OR PRINT ALL INFORMATION SEE INSTRUCTIONS ON REVERSE 1. Grantor's Name _________________________________________________ Phone: ___________________________ 2. Grantee's Name _________________________________________________ Phone: ___________________________ Grantee's Address__________________________________________________________________________________ 3. Address of Property ________________________________________________________________________________ 4. Tax billing address _________________________________________________________________________________ 5. Are there buildings on the land? Yes No If yes, Check type: 1, 2 or 3 family dwelling Condominium Apartment, No. of Units ___________________________________ Manufactured (mobile) home Farm buildings Other _______________________________________________ If land is vacant, what is intended use? _______________________________________________________________ 6. Conditions of sale (check all that apply) Grantor is relative Part interest transfer Land Contract ___ Trade Life estate Leased fee Leasehold Mineral rights reserved Gift ___ Grantor is mortgagee ____Other __________________________________________________________________ 7. a) New mortgage amount (if any) .............................................................................................................. $ ________________ b) Balance assumed (if any) ......................................................................................................................... $ ________________ c) Cash (if any) .............................................................................................................................................. $ ________________ d) Total consideration (add lines 7a, 7b and 7c) ....................................................................................... $ ___________0.00_ e) Portion, if any, of total consideration paid for items other than real property................................ $ ________________ f) Consideration for real property on which fee is to be paid (7d minus 7e) ........................................ $ ________________ g) Name of mortgagee _____________________________________________________________ h) Type of mortgage Conv. F.H.A. V.A. Other _________________ i) If gift, in whole or part, estimated market value of real property ...................... $ _______________ 8. Has the grantor indicated that this property is entitled to receive the senior citizen, disabled person or surviving spouse homestead exemption for the preceding or current tax year? Yes No If yes, complete form DTE 101. 9. Has the grantor indicated that this property qualified for current agricultural use valuation for the preceding or current tax year? Yes No If yes, complete form DTE 102. 10. Application for owner-occupancy (2.5% on qualified levies) reduction. (Notice: Failure to complete this application prohibits the owner from receiving this reduction until another proper and timely application is filed.) Will this property be grantee's principal residence by Jan. 1 of next year? Yes No If yes, is the property a multi-unit dwelling Yes No I declare under penalties of perjury that this statement has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement. ____________________________________________________ Signature of grantee or representative _____________________________ Date DTE Use Only DTE Use Only DTE Use Only Consideration DTE Use Only Valid Sale 1 Yes 2 No _____________ Receipt Number Receipt for Payment of Conveyance Fee The conveyance fee required by Ohio Revised Code section (R.C. 319.54(G)(3) and, if applicable, the fee required by R.C. 322, in the total amount of $_____________, has been paid by _______________ and received by the ____________Cuyahoga County Auditor. _____________________________________________________ County Auditor __________________________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Cuyahoga County Fiscal Department - Real Property Transfers Instrument #: Trans. Date: Verified by: Sale Verification Questionnaire Parcel Number: Sale Date: Sale Amount: Name Name Prop Address: Parcels in Sale: SELLER City,State, Zip Phone Email BUYER Address Address City,State, Zip Phone Email Please answer the following questions: 1. Were there any special conditions affecting the sale? 5. Was any personal property, such as furniture, equipment, machinery, livestock, business inventory, included in the sale price? O O O O O O O O O O O O O O O Sale between family members. Sale between two affiliated businesses. Auction Sale Forced Sale or Sheriff's Sale Sale involved a government agency or public utility. Buyer is a religious or charitable organization. Land contract or contract for deed. Sale involves only a partial interest. Sale includes trade or exchange or properties. Sale by judicial order NONE OF THE ABOVE O Yes O No If yes, describe: Est. Value of Personal Prop. Incl. in Sale: $ 6. Have there been any recent changes to the property? O O No Addition(s) O O Demolition Renovations When was work completed? Estimated Cost of Work Done: $ / / 7. Does the buyer hold title to any adjoining property? O Yes O No 8. Was an appraisal done on the property? O Yes O No 9. Were any delinquent taxes assumed by the purchaser? 2. What was the use of the property at time of sale? Single Family Residence Multifamily Residence Apartment Building Other O O O Vacant Lot Retail Industrial O No O Yes - Amount: