Fill and Sign the Connecticut Conveyance Form

STATEMENT - REAL ESTATE CONVEYANCE TAX Name of Grantor ______________________ Name of Grantee __________________________ To Town Clerk of , Connecticut: The following information is submitted with reference to property at _____________________ _____________________________________________________________________________ and in accordance with Secs. 12-494 to 12-504, inclusive, of the Connecticut General Statutes: Check and insert applicable pertinent data. 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; [ ] The instrument is one that the State of Connecticut is prohibited from taxing by the laws or Constitution of the United States. Cite statutory or 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. Signed ______________________ Type name here: Seller or Representative Date _________________________ Exact Sale Price $ _____________________ x .0011 = $ _______________________________ 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. Real Estate Conveyance Tax Statement