B117 L48 G1-2-7-8TO BE FILED Real Estate Transfer Statement
Fq--
WITH REGISTE
This Statement is Confidential — for Tax Officials Only
OF DEEDS 0 Read instructions on reverse side 521
THE DEED WILL NOT RE RECORDED UNLESS THIS STATEMENT IS SIGNED AND LINES 1 THROUGH 19 ARE PROPERLY COMPLETED --�
COUNTY ASSESSOR'S USE ONLY
County Name
County No.
I Sales No.
Location I.D.
COUNTY ASSESSOR'S USE ONLY
Property Type
(1) ❑ Single Family (4) ❑Commercial (7) ❑Agricultural (Total
Township
No. of Acres )
Quar.
(2) ❑ Multi Family (5) [:]Industrial(8) LIMineral Interests
Block
1 Date of Sale
2 Date of Deed
(3) i.l Home Sites (6) ❑Recreational (9) ❑OYher
(Cabins, etc.)
ty;;)
Month Day Year
Month Day Year
3 Grantor's Name, Address, and Telephone
4 Grantee's Name, Address, and Telephone
Grantor's Name (Seller)
Grantee's Name (Buyer)
- - t , § ,
., J „t., t, " F-,, I ,t..
Street orpt.her Mailing Address
Street or`gtl er Mailir g Address
3 L
C }g State _ ,r ap..Cotle
�k 11� '.1-.'. 7 .'.'i.-, a, 1. il..4a.6:i a:, L: `� 4t' ,
City ., F , rg Fate Zip Code
x> d...�..i....„ L. �,'4; t R. U U a:1
Telephone Number
Teleph!ne,Nui ber .
U 4191
5 Federal Employer Identification or Social Security Number ,Y
of Grantee(s) (if more than two, attach list) �.� d s-� t#,3 t1 .1. J6y
6 Type of Deed
tp,uu t.tt
/ i ype, Ot I ransrer
Sale ❑ Gift ❑ Exchange ❑ Foreclosure ❑ Satisfaction of Contract ❑ Other (explain)
8 Ownership Transferred in Full (if no, explain) 9 Was sale between relatives? (if yes, state relationship)
YES ❑ NO ❑ YES `t'.1 N0
10 If the real estate was transferred for nominal 11 Was mortgage assumed? (if yes, state amount and interest rate)
consideration, what is the current market value? $ ❑ YES I] NO $ %
12 Does this conveyance divipe a current 1 3 Was sale throu�g�h::1 a real estate agent? 14 Was real estate purchased for same use? (if no, explain)
parcel of land? [:]YES NO [:]YES NO ❑ YES ❑ NO
15 Address of Property
16 Legal Description
t ik
City
State
Lip Code
ab,< L; 7, s"" vu..xlt z 7
17 Total purchase price including any liabilities assumed ................. .. 17 $ 75cl .00
18 Was non real property included in purchase? [:]Yes (D No (If yes, enter amount and attach itemized list) ....... 18 $ 100
19 Adjusted purchase price paid for real estate (line 17 minus line 18) ............................... 19 $ 7 1t o i00
Under penalties of perjury, I declare that I have examined this statement and that it is, to the best of my knowledge and belief,
true and correct, and that I am duly authorized to sign this statement.
sign
here Signature'..VMS-
at�—---
20 Date Deed Recorded
Month Day—Year—$
121 Value of Stamp or Exempt Number
22 Deed Book
23 Deed Page
COUNTY ASSESSOR'S USE ONLY
24 Parcel Identification
28 Agricultural Land
Township
Section
Quar.
I Subdivision
Block
Parcel Number
LVG
No, of Acres
LVG
No. of Acres
25 Improved Parcels
Arch Type
Occ. Code
CC
Quality
No. of Stories
Story Height
Floor Area
Basement
Finish
Garage Stall
Garage Type
Year Built
Modernization/Rehab
Miscellaneous
RCN
$ 00
Miscellaneous
Depreciation Study Reason No.
❑ YES ❑ NO
Does land adjoin current operating Irr.
unit?
❑ YES ❑ NO
Type
Total Acres/Lots
26 Platted Lots
Zoning
Irreg.
Front
Depth
29 Land value
29
(
$ 100
Lot Size
Street Improvement
Site Improvement
30 Improvement value ...
30
�
$ j 00
27 Should this sale be used in an assessment/sales If no, give nonuseable sales code
ratio study? ❑ YES ❑ NO
31 Total value (line 29 plus
line 30 ..... .
31
_
$ 00
IveDraska uepartMent of Revenue corm No. 2 -14b -b/ Rev. 10-85 Authorized by Section /16-214, //-132/, //-1328 R.R.S. 1943
Supersedes 2-146-67 Rev. 11-79
COUNTY ASSESSOR — White and Canary Copies NEBRASKA DEPARTMENT OF REVENUE — Pink Copy GRANTEE — Goldenrod Copy
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