Date of Transfer of Title
PERSONALLY appeared before me
the undersigned, who being duly sworn, deposes and says:
I have read the information on this Affidavit and I understand such information
The property is being
transferred by _______________________and is located at
_________________________, __________ County having TMS No. ______________.
The Deed is
(a) ______ Subject to the deed recording fee as a transfer for consideration paid or to be paid in money or money's worth.
(b) ______ Subject to the deed recording fee as a transfer between a corporation, a partnership, or other entity and a stockholder, partner, or owner of the entity, or is a transfer to a trust or as distribution to a trust beneficiary.
(c) ______ EXEMPT from the deed recording fee because (Exemption NO. _____) (Explanation, if required)
(If exempt, please skip items 4-6, and go to item 7 of this affidavit)
Check one of the following if either item 3(a) of item 3(b) above has been checked:
(a) ______ The
fee is computed on the consideration paid or to be paid in money or money's
worth in the amount of $ ____________.
(b) ______ The fee is computed on the fair market value of the realty which is $_________________
(c) ______ The fee is
computed on the fair market value of the realty as established for property
tax purposes which is $_________________
Check YES___ or NO ______ to
the following: A lien or encumbrance existed on the land, tenement, or
realty before the transfer and remained on the land, tenement, or realty after
the transfer. If “YES” the amount of the outstanding balance of this
lien or encumbrance is $______________.
The DEED Recording Fee is computed as follows:
$ _________ the amount listed in item 4 above
_________ the amount listed in item
5 above (no amount place zero)
_________Subtract Line 6(b) from Line 6(a) and place the result.
The deed recording fee due is based on the amount listed on Line 6(c) above and the deed recording fee due is: $ _________.
As required by Code Section 12-24-70, I state that I am a responsible person who was connected with the transaction as follows: ____________.
I understand that a person
required to furnish this affidavit who willfully furnishes a false or
fraudulent affidavit is guilty of a misdemeanor and, upon conviction, must be
fined not more than one thousand dollars or imprisoned not more than one year,
SWORN to before me
_____ day of
Print or Type Name Here
Notary Public for
No guidelines are available for
this form at this time.