REV-183 - Realty Transfer Tax Statement of Value
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
FAILURE TO COMPLETE THIS FORM PROPERLY OR ATTACH REQUESTED DOCUMENTATION MAY RESULT
IN THE RECORDER’S REFUSAL TO RECORD THE DEED.
A. CORRESPONDENT –
All inquiries may be directed to the following person:
Name Telephone Number:
Mailing Address City State ZIP Code
B. TRANSFER DATA
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
Was transaction part of an assignment or relocation?
o
Y
o
N
1. Actual Cash Consideration 2. Other Consideration 3. Total Consideration
4. County Assessed Value 5. Common Level Ratio Factor 6. Computed Value
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
Bureau of Individual Taxes
PO BOX 280603
Harrisburg, PA 17128-0603
RECORDER’S USE ONLY
State Tax Paid
Book Number
Page Number
Date Recorded
REALTY TRANSFER TAX
STATEMENT OF VALUE
See reverse for instructions.
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.
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REV-183 EX (2-15)
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