COMPANY NAME: REAL ESTATE TRANSACTIONS IN 20 PURCHASE/CONVEYANCE COUNTY OR CITY: DISTRICT OR TOWN: DESCRIBE TRANSACTION: GRANTEE/GRANTOR: DESCRIPTION (include facility222s name): SIZE: LOCAL MAP NUMBER: CONSIDERATION: DATE OF DEED: DATE DEED DELIVERED: DATE DEED RECORDED: DEED BOOK: PAGE: LIST IMPROVEMENTS: NOTE: ALL OF THIS INFORMATION MAY NOT BE AVAILABLE TO YOU, HOWEVER PLEASE FILL IN AS COMPLETELY AS POSSIBLE. NOTE: REAL ESTATE LEASED BY YOUR COMPANY ON WHICH YOU OWN THE IMPROVEMENTS ARE TO BE INCLUDED. PLEASE FILL IN AS MUCH INFORMATION AS AVAILABLE. (ATTACH COPY OF DEED AND PLAT TO THIS STATEMENT) American LegalNet, Inc. www.FormsWorkFlow.com