Form Op-236 - Connecticut Real Estate Conveyance Tax Return Page 3

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Department of Revenue Services
OP-236 Schedule A - Grantors
State of Connecticut
Supplemental Information for Connecticut
OP236A 1016W 01 9999
Real Estate Conveyance Tax Return
(Rev. 10/16)
Go Back to OP-236
Use OP-236 Schedule A to provide the required information if there are additional grantors/sellers. If the grantor is a partnership,
S corporation, limited liability company (LLC), estate, or trust, enter the name, address, and taxpayer identifi cation number of the partners,
shareholders, members, or benefi ciaries. If a partner, shareholder, member or benefi ciary of the grantor is an LLC or a qualifi ed subchapter
S corporation (QSS), enter the name of such entity, its address and tax identifi cation number. Do not combine grantors/sellers and
grantee/buyers on the same schedule.
Town
Was the transaction completed on one deed?
Date conveyed
/
/
__ __
__ __
__ __ __ __
Yes
No
m m
d d
y y y y
Location of property conveyed
Date recorded
/
/
__ __
__ __
__ __ __ __
m m
d d
y y y y
Name of grantor as shown on the deed
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code
Last name, fi rst name, middle initial
Taxpayer identifi cation number
SSN
FEIN
Address after conveyance
City or town
State
ZIP code

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