Transfer Tax Affidavit (Shasta)

1450 Court Street, Suite 208, Redding, CA 96001-1667 TEL: (530) 225-5671 FAX: (530) 225-5152 California Relay Service at 711 or 800-735-2922 Updated 7/7/2017 COUNTY OF SHASTA OFFICE OF THE ASSESSOR-RECORDER LESLIE MORGAN, ASSESSOR-RECORDER TRANSFER TAX AFFIDAVIT LOCATION OF PROPERTY: Assessor222s Parcel Number(s): Street Address: THE RECORDER RESERVES THE RIGHT TO REPORT POTENTIALLY FRAUDULENT RECORDINGS TO THE DISTRICT ATTORNEY222S REAL ESTATE FRAUD UNIT. IS THIS A GIFT IN WHOLE OR IN PART? ES NO (If yes, give a complete explanation. If no, proceed to other side of NAME OF TRANSFEROR/DONOR: NAME OF TRANSFEREE/DONEE: Please be aware that certain gifts in excess of $14,000 per calendar year may trigger a Federal Gift Tax. In such cases, the Transferor (donor) may be required to file Form 709 (Federal Gift Tax Return) with the Internal Revenue Service. Please also be aware that information stated on this document may be given and used by governmental agencies, including the Internal Revenue Service. I, , declare under the penalty of perjury, that I have read the aforementioned paragraph and acknowledge that a Federal Gift Tax may be triggered. Signature Phone Number American LegalNet, Inc. www.FormsWorkFlow.com 1450 Court Street, Suite 208, Redding, CA 96001-1667 TEL: (530) 225-5671 FAX: (530) 225-5152 California Relay Service at 711 or 800-735-2922 Updated 7/7/2017 COUNTY OF SHASTA OFFICE OF THE ASSESSOR-RECORDER LESLIE MORGAN, ASSESSOR-RECORDER DO YOU CONTEND THAT NO TRANSFER TAX IS DUE FOR REASON OTHER THAN GIFT? YES NO (If yes, complete this section.) If yes, explain fully: (1) The nature of this transaction; and (2) The reason why you contend no transfer tax is due (Use additional papers if necessary and attach copies of records or documents supporting your claim.) Transfers involving legal entities must provide: - Copy of the Articles of Organization/Bylaws, Operating Agreement of an LLC or Partnership Agreement - Documentation which provides the names of individuals and specific percentages held by each individual both prior to and following this transfer. Please explain: I DECLARE OR AFFIRM UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature Print Name Address Transferor Transferee Phone Number Place of Execution (City, County, State) Date of Execution American LegalNet, Inc. www.FormsWorkFlow.com