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Real Property Conveyance Fee Statement of Value and Receipt
DTE 100
If exempt by Ohio Revised Code section 319.54(G)(3), use form DTE 100(ex)
Rev 1/14
FOR COUNTY AUDITOR’S USE ONLY
Type
Tax list
County
Tax Dist
Date
Instrument
year
number
number
Property located in ____________________________________________________________ taxing district
Number
Name on tax duplicate ____________________________________________ Tax duplicate year __________
Permanent Parcel Number _______________________________________ Map book _____ Page ______
Description ___________________________________________________
Platted
Unplatted
No. of Parcels
Auditor’s comments:
Split
New plat
New improvements
Partial value
C.A.U.V.
Building removed
Other __________________________________
DTE Code No.
GRANTEE OR REPRESENTATIVE MUST COMPLETE ALL QUESTIONS IN THIS SECTION
Neigh. Code
TYPE OR PRINT ALL INFORMATION
SEE INSTRUCTIONS ON REVERSE
1. Grantor’s Name _________________________________________________ Phone: ___________________________
2. Grantee’s Name _________________________________________________ Phone: ___________________________
No. of Acres
Grantee’s Address__________________________________________________________________________________
3. Address of Property ________________________________________________________________________________
4. Tax billing address _________________________________________________________________________________
Land Value
5. Are there buildings on the land?
Yes
No If yes, Check type:
1, 2 or 3 family dwelling
Condominium
Apartment, No. of Units ___________________________________
Manufactured (mobile) home
Farm buildings
Other _______________________________________________
Bldg. Value
If land is vacant, what is intended use? _______________________________________________________________
6. Conditions of sale (check all that apply) Grantor is relative
Part interest transfer
Land Contract
___ Trade
Life estate
Leased fee
Leasehold
Mineral rights reserved
Gift
Total Value
___ Grantor is mortgagee
____Other __________________________________________________________________
7. a) New mortgage amount (if any) ……………………………………………………………………………………….….…… $ ________________
b) Balance assumed (if any) …………………………………………………………………………………………..…………….. $ ________________
DTE Use Only
c) Cash (if any) …………………………………………………………………………………………………………………..……..... $ ________________
d) Total consideration (add lines 7a, 7b and 7c) …………………………..…………………………………………….… $ ___________0.00_
e) Portion, if any, of total consideration paid for items other than real property………………………..… $ ________________
DTE Use Only
f) Consideration for real property on which fee is to be paid (7d minus 7e) …………………………………. $ ________________
g) Name of mortgagee _____________________________________________________________
h) Type of mortgage
Conv.
F.H.A.
V.A.
Other _________________
DTE Use Only
i) If gift, in whole or part, estimated market value of real property …………………. $ _______________
8. Has the grantor indicated that this property is entitled to receive the senior citizen, disabled person or surviving spouse
Yes
No If yes, complete form DTE 101.
homestead exemption for the preceding or current tax year?
9. Has the grantor indicated that this property qualified for current agricultural use valuation for the preceding or current
Consideration
tax year?
Yes
No If yes, complete form DTE 102.
10. Application for owner-occupancy (2.5% on qualified levies) reduction. (Notice: Failure to complete this application
prohibits the owner from receiving this reduction until another proper and timely application is filed.) Will this property
DTE Use Only
be grantee’s principal residence by Jan. 1 of next year?
Yes No If yes, is the property a multi-unit dwelling
Yes
No
Valid Sale
1 Yes
2 No
I declare under penalties of perjury that this statement has been examined by me and to the best of my knowledge and
belief is a true, correct and complete statement.
____________________________________________________
_____________________________
_____________
Signature of grantee or representative
Date
Receipt Number
Receipt for Payment of Conveyance Fee
The conveyance fee required by Ohio Revised Code section (R.C. 319.54(G)(3) and, if applicable, the fee required by R.C. 322, in the
total amount of $_____________, has been paid by _______________ and received by the ____________Cuyahoga County Auditor.
_____________________________________________________
__________________________________________________
County Auditor
Date