Form 521mh - Manufactured Housing Transfer Statement
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FORM
Manufactured Housing Transfer Statement
521MH
1 County Name
2 County Number
4
3 Date of Sale
Mo.________ Day________ Yr.________
5 Seller’s Name, Address, and Telephone (Please Print)
6 Buyer’s Name, Address, and Telephone (Please Print)
Seller’s Name
Buyer’s Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
Telephone Number
(
)
(
)
7 Type of Transfer
Sale
Auction
Gift
Exchange
Foreclosure
Satisfaction of Contract
Life Estate
Other (Explain.) ______________________
8 Was ownership transferred in full? (If No, explain the division.)
9 Was the home purchased as part of an IRS like-kind exchange? (IRC § 1031 Exchange)
YES
NO _________________________________________________
YES
NO _________________________________________________
10 Was the sale between relatives? (If Yes, check the appropriate box at right.)
YES
NO
Spouse
Parents and Child
Brothers and Sisters
Family Corp. or Partnership
Grandparents and Grandchild
Step-parent and Step-child
Aunt or Uncle to Niece or Nephew
Other ____________
11 What is the current market value of the manufactured housing?
12 Was the mortgage assumed? (If Yes, state amount and interest rate.)
_____________________________________________________________
YES
NO
$ ________________________ at _____________ %
13 Was the sale through an agent?
YES
NO If Yes, include the name of the agent: _______________________________________________________
14 Length (Without Hitch)
15 Width
16 Make
17 Model
18 Year
19 Location of the Home Before Sale
20 Name and Address of Person to Whom the Tax Statement Should be Sent
19a Location of the Home After Sale
21 Name and Address of the Land Owner
22 Legal Description of the Land
23 Total purchase price, including any liabilities assumed ...................................................................
23
24 Was nonreal property included in the purchase?
YES
NO (If Yes, complete 24a, 24b,
and 24c indicating the cost amount of each.)
24a Furnishings ..................................................................................... 24a
24b Moving Costs .................................................................................. 24b
24c Set-up Costs ................................................................................... 24c
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 Buyer or Authorized Representative
Telephone Number
sign
here
Signature of Buyer or Authorized Representative
Title
Date
This statement should be filed with the county clerk (or the county treasurer if he or she is the
designated county official) in the county where the application for title is made.
Retain a copy for your records.
96-216-2001 Rev. 7-2013 Supersedes 96-216-2001 Rev. 8-2011
Authorized by Neb Rev Stat § 60-147
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