Form 521 - Real Estate Transfer Statement
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Real Estate Transfer Statement
FORM
521
• To be filed with the Register of Deeds.
• Read instructions on reverse side.
THE DEED WILL NOT BE RECORDED UNLESS THIS STATEMENT IS SIGNED AND ITEMS 1-25 ARE ACCURATELY COMPLETED
1
2
3
4
County Name
County Number
Date of Sale
Date of Deed
Mo.
Day
Yr.
Mo.
Day
Yr.
Select County & County Number
5
Grantor’s Name, Address, and Telephone (Please Print)
6
Grantee’s Name, Address, and Telephone (Please Print)
Grantor’s Name (Seller)
Grantee’s Name (Buyer)
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
Telephone Number
(
)
(
)
7
PROPERTY CLASSIFICATION NUMBER. Check one box in categories A and B. Check C if property is also a mobile home.
(A) Status
(B) Property Type
(C)
(1)
Improved
(1)
Single Family
(4)
Industrial
(7)
Mineral Interests-Nonproducing
(9)
State Assessed
(1)
Mobile Home
(2)
Unimproved
(2)
Multi-Family
(5)
Agricultural
(8)
Mineral Interests-Producing
10)
Exempt
(3)
IOLL
(3)
Commercial
(6)
Recreational
8
Type of Deed
Corrective
Land Contract
Personal Rep.
Bill of Sale
9
IRC § 1031 Exchange?
Yes
No
(Was the transfer an IRS like-kind exchange?)
Warranty
Sheriff
Executor
Mineral
Cemetery
Quit Claim
Conservator
Partition
Trust
Other__________
10
Type of Transfer
Sale
Gift
Foreclosure
Revocable Trust
Court Decree
Satisfaction of Contract
Auction
Exchange
Life Estate
Irrevocable Trust
Partition
Other (Explain.) _________________
11
12
Was ownership transferred in full? (If No, explain the division.)
Was real estate purchased for same use? (If No, state the intended use.)
YES
NO ____________________________________________________________
YES
NO ________________________________________
13
Was the transfer between relatives, or if to a trustee, are the trustor and beneficiary relatives? (If Yes, check the appropriate box.)
YES
NO
Spouse
Parents and Child
Family Corporation, Partnership or LLC
Grandparents and Grandchild
Brothers and Sisters
Aunt or Uncle to Niece or Nephew
Other ________________
14 What is the current market value of the real property?
15 Was the mortgage assumed? (If Yes, state the amount and interest rate.)
YES
NO
$
%
16 Does this conveyance divide a current parcel of land?
17 Was transfer through a real estate agent? (If Yes, include the name of the agent.)
YES
NO
YES
NO __________________________________________________
18 Address of Property
19 Name and Address of Person to Whom Tax Statement Should be Sent
20
Legal Description
21
If agricultural, list total number of acres ___________________ .
$
22 Total purchase price, including any liabilities assumed
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
$
23 Was nonreal property included in the purchase?
YES
NO (If Yes, enter amount and attach itemized list.) . .
23
$
0.00
24 Adjusted purchase price paid for real estate (line 22 minus line 23) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
25 If this transfer is exempt from the documentary stamp tax, list the exemption number ___________________ .
Under penalties of law, I declare that I have examined this statement and that it is, to the best of my knowledge and belief, true, complete, and
correct, and that I am duly authorized to sign this statement.
Print or Type Name of Grantee or Authorized Representative
Telephone Number
sign
here
Signature of Grantee or Authorized Representative
Title
Date
REGISTER OF DEEDS’ USE ONLY
FOR DEPT. USE ONLY
27 Value of Stamp or Exempt Number
28 Deed Book
29 Deed Page
30
26 Date Deed Recorded
$
Mo.
Day
Yr.
Nebraska Department of Revenue
Authorized by Neb. Rev. Stat. §§ 76-214, 77-1327
Form No. 96-269-2008 Rev. 8-2011 Supersedes 96-269-2008
GRANTEE — Please retain a copy of this document for your records.
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