Rev. 1/2009 Date: _______________ File No.: ____________________ STATEMENT OF CONVEYANCE OF PROPERTY ENROLLED IN AN AGRICULTURAL DISTRICT Grantor's Name ________________________________________________________________ Grantee's Name ________________________________________________________________ Parcel(s) Number _______________________________________________________________ The grantor of the property referred to above states that the property has qualified for enrollment in an Agricultural District under section 929.02 of the Ohio Revised Code for the preceding or the current tax year. The grantee is aware that if the property does not continue to so qualify, either for the current or for the succeeding tax year, it will be subject to a penalty equal to the amount described in sections 929.02 and 5713.34 of the Ohio Revised Code. Furthermore, the grantor and the grantee have considered and accounted for the total estimated amount of such penalty, if any, to the satisfaction of both the grantee and the grantor. Does the Grantee intend to: ____1. Stay in current Agricultural District program which expires in _________. ____2. Pay penalty at the time of transfer. ____3. Have penalty added to next year's tax bill. ____________________________________ Signature of Grantor or Representative ____________________________________ Signature of Grantee or Representative Sworn to or affirmed in my presence, this ______ day of _____________, ______. ____________________________________ Notary Public Amount of penalty for early withdrawal from an Agricultural District (3.25 % Tax Year 2015) $______________________ Endorsement by County Auditor: Upon presentation of this instrument, the County Auditor shall endorse it, provide copies at that time to grantees/grantors and/or representatives, and maintain a copy on file evidencing delivery to the County Auditor. County Auditor (Deputy): _____________________________ Date: __________ American LegalNet, Inc. www.FormsWorkFlow.com