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 Property located in Name on tax duplicate Acct. or permanent parcel no. Description Auditor's comments: Split C.A.U.V New plat New improvements Other Partial value Tax duplicate year Map book Platted taxing district Page Unplatted Number No. of Parcels Building removed DTE Code No. Grantee or Representative Must Complete All Questions in This Section Type or print all information. See instructions on reverse. Neigh. Code 1. Grantor's name 2. Grantee's name 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) Trade Life estate Leased fee Grantor is mortgagee Other Phone Phone No. of Acres Land Value Bldg. Value Grantor is relative Part interest transfer Land contract Leasehold Mineral rights reserved Gift Total Value 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) ......................................................................$ 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 DTE Use Only DTE Use Only DTE Use Only 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 it is a true, correct and complete statement. Signature of grantee or representative Date Receipt Number DTE Use Only Valid sale 1. Yes 2. No Consideration 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 county auditor. County auditor Date American LegalNet, Inc. www.FormsWorkFlow.com Instructions to Grantee or Representative for Completing Real Property Conveyance Fee Statement of Value Complete lines 1 through 10 in box. DTE 100 Rev. 1/14 Page 2 WARNING: All questions must be completed to the best of your knowledge to comply with Ohio Revised Code (R.C.) section 319.202. Persons willfully failing to comply or falsifying information are guilty of a misdemeanor of the first degree (R.C. section 319.99(B)). It is important that the information on this form be accurate as it will be used to determine whether all real property, including this property, is uniformly assessed for real property tax purposes. Note: The county auditor has discretionary power under R.C. section 319.202(A) to request additional information in any form of documentation deemed necessary to verify the accuracy of the information provided by the grantee on the front of the form. Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 List grantor's name as shown in the deed or other instrument conveying this real property. List grantee's name as shown in the deed or other instrument conveying this real property and the grantee's mailing address. List address of property conveyed by street number and name. List complete name and address to which tax bills are to be sent. CAUTION: Each property owner is responsible for paying the property taxes on time even if no tax bill is received. If there are no buildings on the land conveyed, check "no." If there are buildings, check "yes" and the appropriate box that describes the type of buildings. If other, describe briefly the type of buildings, such as "office building." Show any special condition of sale that would affect the consideration. If any of the special conditions noted are involved, check the appropriate box. Briefly describe other conditions in the space provided. a) b) c) d) e) f) g) h) i) Line 8 Enter amount of new mortgage on this property (if any). Enter amount of the balance assumed on an existing mortgage (if any). Enter cash paid for this property (if any). Add lines 7a, 7b and 7c. If any portion of the consideration reported on line 7d was paid for items other than real property, enter the portion of the consideration paid for those items. Deduct line 7e from line 7d and enter the difference on this line. List mortgagee or mortgagees (the party who advances the funds for a mortgage loan). Check type of mortgage. In the case of a gift, in whole or part, enter the estimated price that the real estate would bring in the open market. If the grantor has indicated that the property to be conveyed will receive the senior citizen, disabled person or surviving spouse homestead exemption for a proceeding or current tax year under R.C. section 323.152(A), grantor must complete DTE 101 or submit a statement that complies with the provisions of R.C. section 319.202(A)(2), and the grantee must submit such form to the county auditor along with this statement. If the grantor