Form Rev-181 Cm - Application For Tax Clearance Certificate - 2008 Page 4
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4SCHEDULE A - STATEMENT OF ACQUISITION AND/OR DISPOSITION OF PENNSYLVANIA REAL ESTATE WITHIN FIVE YEARS FROM THE DATE OF THIS APPLICATION
Name of Transferee (EE)
Original Cost
or Transferor (OR).
Date of
Property Location by
Acquisition
County
Actual Consider-
Actual Monetary Worth
Amount of PA Realty
Indicate each by symbol
Transfer
Local Political Subdivision
Date
Land
Building
Assessed Value
ation including
(Market Value)
Stamps Affixed to
Explanation
*
**
EE or OR.
& County
Encumbrance
at Time of Transfer
Document
*
Assumed
Original Cost
Property Location by
Acquisition
County
Actual Consider-
Actual Monetary Worth
Amount of PA Realty
Local Political Subdivision
Date
Land
Building
Assessed Value
ation including
(Market Value)
Stamps Affixed to
Explanation
*
**
& County
Encumbrance
at Time of Transfer
Document
*
Assumed
SCHEDULE B
STATEMENT OF
ALL
PENNSYLVANIA
REAL ESTATE
NOW OWNED
List all Real Estate now owned in PA that the business will dispose of prior to or at the time of the action for which a clearance is required.
If under agreement of disposition, attach copy of executed agreement for each property so affected.
* Complete if applicable. If transfer represents less than a full fee simple interest in the property, explain on a separate sheet of paper.
** If no Realty Transfer Tax was paid, explain on attached sheet or in “Explanation” column.
If application is for a Bulk Sale Clearance Certificate, attach a list of PA properties that will be retained. For each property, provide the complete address, including county,
date of acquisition and nature of property (residential, industrial, acreage, commercial or farmland). If none, state none.
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