STATEMENT – REAL ESTATE CONVEYANCE TAX

Name of Grantor: 						
Name of Grantee:							
To 		 Clerk of 			, Connecticut:
The following information is submitted with reference to the property at the address:
								
and in accordance with Secs. 		 to 		, inclusive, of the Connecticut General Statutes:
[   ] Full purchase price, including assumed or existing mortgages, liens, etc. $				
[   ] Not subject to tax for the following reason (check appropriate reason):
	[   ] No consideration paid;
	[   ] Consideration less than $2,000.00;
[   ] The instrument is one that the State Constitution is prohibited from taxing by the laws or Constitution of the United States. Cite statutory/constitutional provision: 			;
[   ] The State of Connecticut or a Connecticut political subdivision is either the grantor or grantee of this instrument;
[   ] Tax deed;
[   ] Deed of partition
[   ] Deed made pursuant to a statutory merger or consolidation from a constituent corporation to the continuing or new corporation
[   ] Deed made pursuant to a decree of the Superior Court under Section 46b-81, 49-24, or 52-495 of the Connecticut General Statutes.
No deduction shall be made for the amount of any mortgages or liens remaining upon the property at the time of the sale even though not assumed by the grantee
(Purchase Price) $			  *  (Municipal Rate) 		%  =  $				
								(Conveyance Tax)

x									Date: 				
Print Name - Seller or Representative:
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