REV-183 EX (2-15)
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. If more space is needed, please attach additional sheets.
A Statement of Value (SOV) is not required if the transfer is wholly exempt from tax based on family relationship or public utility ease-
ment. However, it is recommended that a SOV accompany all documents filed for recording.
A. CORRESPONDENT – All inquiries may be directed to the following person:
START
Name
Telephone Number:
Mailing Address
City
State
ZIP Code
B. TRANSFER DATA
MM/DD/YYYY
Date of Acceptance of Document
/
/
Grantor(s)/Lessor(s)
Telephone Number:
Grantee(s)/Lessee(s)
Telephone Number:
Mailing Address
Mailing Address
City
State
ZIP Code
City
State
ZIP Code
C. REAL ESTATE LOCATION
Street Address
City, Township, Borough
County
School District
Tax Parcel Number
D. VALUATION DATA
o
o
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. Computed Value
x
=
E. EXEMPTION DATA - Refer to instructions for exemption status.
1a. Amount of Exemption Claimed
1b. Percentage of Grantor’s Interest in Real Estate 1c. Percentage of Grantor’s Interest Conveyed
$
%
%
2. Check Appropriate Box Below for Exemption Claimed.
o
Will or intestate succession.
(Name of Decedent)
(Estate File Number)
o
Transfer to a trust. (Attach complete copy of trust agreement identifying all beneficiaries.)
o
Transfer from a trust. Date of transfer into the trust
If trust was amended attach a copy of original and amended trust.
o
Transfer between principal and agent/straw party. (Attach complete copy of agency/straw party agreement.)
o
Transfers to the commonwealth, the U.S. and instrumentalities by gift, dedication, condemnation or in lieu of condemna-
tion. (If condemnation or in lieu of condemnation, attach copy of resolution.)
o
Transfer from mortgagor to a holder of a mortgage in default. (Attach copy of mortgage and note/assignment.)
o
Corrective or confirmatory deed. (Attach complete copy of the deed to be corrected or confirmed.)
o
Statutory corporate consolidation, merger or division. (Attach copy of articles.)
o
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
MM/DD/YY
PLEASE SIGN AFTER PRINTING
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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