B43 L9 G11-12 (2)TO BE FILED
WITH REGISTER
OF DEEDS
Real Estate Transfer StatementFORM
This Statement is Confidential — for Tax Officials Only
® Read instructions on reverse side
521
a THE DEED WILL NOT BE RECORDED UNLESS THIS STATEMENT IS SIGNED AND LINES 1 THROUGH 19 ARE PROPERLY COMPLETED
COUNTY ASSESSOR'S USE ONLY
Subdivision
County Name
County No.
Sales No.
Location I.D.
Property Type
(1) ❑ Single Family (4) ❑ Commercial (7) ❑ Agricultural (Total
No. of Acres )
(2) ❑ Multi Family (5) ❑ Industrial (8) ❑ Mineral Interests
(3)Home Sites (6) Recreational (9) Other
❑ ❑ Cabins, etc. ❑
1 Date of Sale
Month Day Year
2 Date of Deed
Month Day Year
3 Grantor's Name, Address, and Telephone
4 Grantee's Name, Address, and Telephone 1
Grant 's are( ler
Grantgm Nam Bu,�e�) �p ^fp
air
Street r er 'i re
' h Street #
Street or M 'i ss
City tate Omaha, Nebrash Zip Code
City {, t iM e es ode
Telephone Number
Telephone Number
330-9323 426-4191
5 Federal Employer Identification or Social Security Number 506 38 9870 6 Type of Deed
of Grantee(s) (if more than two, attach list) TIa r nt- Dee
7 Type of Transfer
lD 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)
El YES ❑ NO ❑ YES KI NO
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 NO $ — % _
12 Does this conveyance divide a current 113 Was sale through a real estate agent? 14 Was real estate purchased for same use? (if no, explain)
parcel of land? ❑ YES C NQ ❑ YES l NO _ yes
15 Address of Property CityState Zip Code
Blasi __14ebraska 68008
16 Legal DescriptionI ave and 12 in Lot , Block 43 ir. the Blair Cemetery,
W ashington County, Nebraska.
17 Total purchase price including any liabilities assumed ............................ ......... 17 $
13 Was non real property included in purchase? ❑ Yes ❑ No 1
res, enter amount and attach itemized list) ............ 113 L$
rchase price paid for real estate (line 17 minus line 18) ...............................:....... .
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.
Signature
20 Date Dead Recorded
Month ' Da
_ Y
Title
REGISTER OF DEEDS' USE ONLY
-� $21 Value of Stamp or ExeTpr Number 22 Deed Book
f r
Year %.
COUNTY ASSESSOR'S USE ONLY
Date
23 Deed
$
182 00
i
00
�QO
24 Parcel Identification
28 Agricultural Land
Township
Section
Quar.
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.
Does land adjoin current operating
Irr. Type
Total Acres/Lots
❑ YES ❑ NO
unit?
❑ YES ❑ NO
26 Platted Lots
Zoning
Irreg.
Front
Depth
29 Land Value .
29
$ , 00
Lot Size Street Improvement Site Improvement
30 Improvement value
30
$ 00
27Should this sale be used in an assessment/sales If no, give nonuseable sales code
31 Total value (line 29 plus
ratio study? ❑ YES ❑ NO
line 30) . . . . . . .
31
$ oo
Nebraska Department of Revenue Form No. 2-146-67- Rev. 10-85 Authorized by Section /6-214, 11-132x, 11-132b H.H.S. is4�3
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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