Form Rev-183 Ex - Realty Transfer Tax Statement Of Value
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2REV-183 EX (04-10)
RECORDER’S USE ONLY
REALTY TRANSFER TAX
State Tax Paid
STATEMENT OF VALUE
Book Number
Bureau of Individual Taxes
Page Number
PO BOX 280603
See reverse for instructions.
Harrisburg, PA 17128-0603
Date Recorded
Complete each section and file in duplicate with Recorder of Deeds when (1) the full value/consideration is not set forth in the deed, (2) the
deed is without consideration or by gift, or (3) a tax exemption is claimed. A Statement of Value is not required if the transfer is wholly exempt
from tax based on family relationship or public utility easement. If more space is needed, attach additional sheets.
A. CORRESPONDENT – All inquiries may be directed to the following person:
Name
Telephone Number:
(
)
Mailing Address
City
State
ZIP Code
B. TRANSFER DATA
C. Date of Acceptance of Document
Grantor(s)/Lessor(s)
Grantee(s)/Lessee(s)
Mailing Address
Mailing Address
City
State
ZIP Code
City
State
ZIP Code
D. REAL ESTATE LOCATION
Street Address
City, Township, Borough
County
School District
Tax Parcel Number
E. VALUATION DATA - WAS TRANSACTION PART OF AN ASSIGNMENT OR RELOCATION?
Y
N
1. Actual Cash Consideration
2. Other Consideration
3. Total Consideration
+
=
4. County Assessed Value
5. Common Level Ratio Factor
6. Fair Market Value
=
x
F. EXEMPTION DATA
1a. Amount of Exemption Claimed
1b. Percentage of Grantor’s Interest in Real Estate 1c. Percentage of Grantor’s Interest Conveyed
Check Appropriate Box Below for Exemption Claimed.
Will or intestate succession.
(Name of Decedent)
(Estate File Number)
Transfer to a trust. (Attach complete copy of trust agreement identifying all beneficiaries.)
Transfer from a trust. Date of transfer into the trust
If trust was amended attach a copy of original and amended trust.
Transfer between principal and agent/straw party. (Attach complete copy of agency/straw party agreement.)
Transfers to the commonwealth, the U.S. and instrumentalities by gift, dedication, condemnation or in lieu of con-
demnation. (If condemnation or in lieu of condemnation, attach copy of resolution.)
Transfer from mortgagor to a holder of a mortgage in default. (Attach copy of mortgage and note/assignment.)
Corrective or confirmatory deed. (Attach complete copy of the deed to be corrected or confirmed.)
Statutory corporate consolidation, merger or division. (Attach copy of articles.)
Other (Please explain exemption claimed.)
Under penalties of law, I declare that I have examined this statement, including accompanying information, and to
the best of my knowledge and belief, it is true, correct and complete.
Signature of Correspondent or Responsible Party
Date
FAILURE TO COMPLETE THIS FORM PROPERLY OR ATTACH REQUESTED DOCUMENTATION MAY RESULT IN
THE RECORDER’S REFUSAL TO RECORD THE DEED.
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