Form Rev-183 Ex - Realty Transfer Tax Statement Of Value
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1
2REV-183 EX (11-04)
RECORDER’S USE ONLY
REALTY TRANSFER TAX
State Tax Paid
STATEMENT OF VALUE
Book Number
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
Page Number
BUREAU OF INDIVIDUAL TAXES
See Reverse for Instructions
PO BOX 280603
Date Recorded
HARRISBURG PA 17128-0603
Complete each section and file in duplicate with Recorder of Deeds when (1) the full value/consideration is not set forth in the deed, (2) when the
deed is without consideration, or by gift, or (3) a tax exemption is claimed. A Statement of Value is not required if the transfer is wholly exempt from
tax based on: (1) family relationship or (2) public utility easement. If more space is needed, attach additional sheet(s).
A. CORRESPONDENT – All inquiries may be directed to the following person:
Name
Telephone Number:
START
Street Address
City
State
Zip Code
B. TRANSFER DATA
Date of Acceptance of Document
Grantor(s)/Lessor(s)
Grantee(s)/Lessee(s)
Street Address
Street Address
City
State
Zip Code
City
State
Zip Code
C. PROPERTY LOCATION
Street Address
City, Township, Borough
County
School District
Tax Parcel Number
D. VALUATION DATA
1. Actual Cash Consideration
2. Other Consideration
3. Total Consideration
+
=
4. County Assessed Value
5. Common Level Ratio Factor
6. Fair Market Value
=
x
E. EXEMPTION DATA
1a. Amount of Exemption Claimed
1b. Percentage of Interest Conveyed
2. Check Appropriate Box Below for Exemption Claimed
Will or intestate succession
(Name of Decedent)
(Estate File Number)
Transfer to Industrial Development Agency.
Transfer to a trust. (Attach complete copy of trust agreement identifying all beneficiaries.)
Transfer between principal and agent. (Attach complete copy of agency/straw party agreement.)
Transfers to the Commonwealth, the United States and Instrumentalities by gift, dedication, condemnation or in lieu
of condemnation. (If condemnation or in lieu of condemnation, attach copy of resolution.)
Transfer from mortgagor to a holder of a mortgage in default. Mortgage Book Number ________ , Page Number ______.
Corrective or confirmatory deed. (Attach complete copy of the prior deed being corrected or confirmed.)
Statutory corporate consolidation, merger or division. (Attach copy of articles.)
Other (Please explain exemption claimed, if other than listed above.)
Under penalties of law, I declare that I have examined this Statement, including accompanying information, and to the best
of my knowledge and belief, it is true, correct and complete.
MM/DD/YYYY
Signature of Correspondent or Responsible Party
Date
PLEASE SIGN AFTER PRINTING
FAILURE TO COMPLETE THIS FORM PROPERLY OR ATTACH APPLICABLE DOCUMENTATION MAY RESULT IN
THE RECORDER’S REFUSAL TO RECORD THE DEED.
Reset Entire Form
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