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Effective On or Before 07/01/16 Page 1 57-006a (03/15/16) CTRL # REAL ESTATE TRANSFER - DECLARATION OF VALUE Please read the instructions comprised in form 57-011 before completing and filing this form. Part I - TO BE COMPLETED BY BUYER, SELLER OR AGENT Date of Instrument Enter the number matching your selection in the box at the end of the line: Deed Contract Seller: Phone Number: Seller Address: City: State: ZIP: email: Buyer: Phone Number: Buyer Address: City: State: ZIP: email: Address of Property Conveyed: City: State: ZIP: Legal Description: Enter the number corresponding to your selection in the box at the end of the line, if applicable. Type of Sale: Sale between related parties/family Sale of partial interest Trade Quit Claim Deed Auction Was this a sale of agricultural land to: Corporation Trust Alien Non-resident Alien Limited Partnership DECLARATION OF VALUE STATEMENT 1. Total Amount Paid 2. Amount Paid for Personal Property 3. Amount Paid for Real Property I hereby declare that the information contained in Part I of this form is true and correct. Printed Name: Phone Number: Signature: Buyer or Seller or Agent or Attorney , , .00 , , .00 , , .00 C O Y Y Y Y M M # # # # # ---PAGE BREAK--- Real Estate Transfer – Declaration of Value, Page 2 Effective on or before 07/01/16 Page 2 57-006b (03/15/16) Part II - TO BE COMPLETED BY THE ASSESSOR Assessed values must be as of January 1 of the year in which the sale occurred. SECTION A: SINGLE CLASSIFICATION Primary Classification: Residential Commercial Industrial Agricultural Multi-residential City/Township: Occupancy: Primary Parcel Number: Year Built: Class Land Building Dwelling Res , .00 , , .00 , , .00 Com , .00 , , .00 Ind , .00 , , .00 Ag , .00 , , .00 , , .00 MultiRes , .00 , , .00 , , .00 Subtotal SECTION B: DUAL CLASSIFICATION Primary Classification: Commercial Industrial Multi-residential City/Township: Occupancy: Primary Parcel Number: Year Built: Class Land Building Dwelling Com , .00 , , .00 Ind , .00 , , .00 MultiRes , .00 , , .00 , , .00 Subtotal Total: Add Subtotal amounts from Sections A and B Enter amount from line 3, page 1 Ratio: Divide Total amount by the amount on line 3, page 1 : % NUTC Jurisdiction Comments: , . , , .00 , , .00 , , .00 , , .00 ---PAGE BREAK--- Effective on or before 07/01/16 Page 1 57-011a (03/15/16) Real Estate Transfer – Declaration of Value Instructions Visit the Department website at for more information. FILING INSTRUCTIONS: Iowa law requires that a “Declaration of Value” statement reflecting the full consideration paid in certain nonexempt real estate conveyances be submitted to the county recorder at the time a deed, contract, instrument, or other writing is presented for recording. The blank area at the top of page 1 of form 57-006, Real Estate Transfer- Declaration of Value, is for use by the county recorder. In this area the recorder will provide the following information: Date of Recording, Book and Page Number or Instrument Number, County, or Real Estate Transfer Tax. Part I of the form is the prescribed “Declaration of Value” statement that must be completed by the buyer or seller or either’s agent for nonexempt transactions. Part II of the form is to be completed only by the assessor. IMPORTANT: This form does not have to be completed for any document presented for recording which clearly indicates on such document that it is an exempt transaction. Refer to Iowa Administrative Code 701- 79.5. If the transaction is exempt, but the reason for exemption is not stated on the actual document presented for recording, Part I of this form must be completed. If this form is not completed accurately and completely for nonexempt transactions by the buyer or seller or either’s agent, the county recorder is required by law to refuse to record the contract, deed or other instrument conveying the affected property. TYPE OF SALE: Enter the number corresponding to your selection in the box at the end of the line on page 1, if applicable. For purposes of indicating a “Sale Between Family Members” only the following relationships are to be considered: Mother Daughter Sister Sister-in-law Stepsister Mother-in-law Daughter-in-law Niece Foster child Foster parent Foster brother Foster sister Father Son Brother Brother-in-law Stepbrother Father-in-law Son-in-law Nephew Grandson Granddaughter Grandfather Grandmother Stepmother Stepfather Stepson Stepdaughter Uncle Aunt DECLARATION OF VALUE STATEMENT: Line 1. Total Amount Paid: Enter the entire and full purchase price of the property transferred, including down payment. Note: Reporting of personal property should conform to the transfer document and any related income tax filings. Line 2. Amount Paid for Personal Property: Enter the amount of the purchase price that was paid for personal property. For residential sales, personal property includes items that are not attached (“built in”) to the home that are normally removed by the owner, when he or she vacates. This includes, but is not limited to, items such as washers, dryers, drapes, stoves, refrigerators, and portable dishwashers. Personal property for commercial or industrial sales includes inventories, as well as equipment and fixtures classified and assessed as personal property. Reporting of personal property should conform to the transfer document and any related income tax filings. Line 3. Amount Paid for Real Property Only: Subtract Line 2 from Line 1 and enter the difference here. ---PAGE BREAK--- Real Estate Transfer – Declaration of Value Instructions, Page 2 Effective on or before 07/01/16 Page 2 57-011b (03/15/16) IMPORTANT: If this transaction is exempt from the transfer tax, you may not be required to complete this form. Exemption numbers 1, 6, 14, or 15 require a Declaration of Value form to be completed. Exceptions Iowa Code 428A.2 1. (DOV required) Any executory contract for the sale of land under which the vendee is entitled to or does take possession thereof, or any assignment or cancellation thereof. 2. Any instrument of mortgage, assignment, extension, partial release, or satisfaction thereof. 3. Any will. 4. Any plat. 5. Any lease. 6. (DOV required for federal agency or instrumentality) Any deed, instrument, or writing in which the United States or any agency or instrumentality thereof or the state of Iowa or any agency, instrumentality, or governmental or political subdivision thereof is the grantor, assignor, transferor, or conveyor; and any deed, instrument or writing in which any of such unit of government is the grantee or assignee where there is no consideration. 7. Deeds for cemetery lots. 8. Deeds which secure a debt or other obligation, except those included in the sale of real property. 9. Deeds for the release of a security interest in property excepting those pertaining to the sale of real estate. 10. Deeds which, without additional consideration, confirm, correct, modify or supplement a deed previously recorded. 11. Deeds between husband and wife, or parent and child, without actual consideration. A cancellation of indebtedness alone which is secured by the property being transferred and which is not greater than the fair market value of the property being transferred is not actual consideration within the meaning of this subsection. 12. Tax deeds. 13. Deeds of partition where the interest conveyed is without consideration. However, if any of the parties take shares greater in value than their undivided interest a tax is due on the greater values, computed at the rate set out in section 428A.1. 14. (DOV required)The making or delivering of instruments of transfer resulting from a corporate merger, consolidation, or reorganization or a merger, consolidation, or reorganization of a limited liability company under the laws of the United States or any state thereof, where such instrument states such fact on the face thereof. 15. (DOV required) Deeds between a family corporation, partnership, limited partnership, limited liability partnership, or limited liability company and its stockholders, partners, or members for the purpose of transferring real property in an incorporation or corporate dissolution or the organization or dissolution of a partnership, limited partnership, limited liability partnership, or limited liability company under the laws of this state, where the deeds are given for no actual consideration other than for shares or for debt securities of the corporation, partnership, limited partnership, limited liability partnership, or limited liability company. For purposes of this subsection, a family corporation, partnership, limited partnership, limited liability partnership, or limited liability company is a corporation, partnership, limited partnership, limited liability partnership, or limited liability company where the majority of the voting stock of the corporation, or of the ownership shares of the partnership, limited partnership, limited liability partnership, or limited liability company is held by and the majority of the stockholders, partners, or members are persons related to each other as spouse, parent, grandparent, lineal ascendants of grandparents or their spouses and other lineal descendants of the grandparents or their spouses, or persons acting in a fiduciary capacity for persons so related and where all of its stockholders, partners, or members are natural persons or persons acting in a fiduciary capacity for the benefit of natural persons. 16. Deeds for the transfer of property or the transfer of an interest in property when the deed is executed between former spouses pursuant to a decree of dissolution of marriage. 17. Deeds transferring easements. 18. Deeds giving back real property to lienholders in lieu of forfeitures or foreclosures. 19. Deeds executed by public officials in the performance of their official duties. 20. Deeds transferring distributions of assets to heirs at law or devisees under a will. 21. Deeds in which the consideration is five hundred dollars or less.