Form 57006a - Real Estate Transfer - Declaration Of Value - Iowa Department Of Revenue
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2*IDRDOV*
REAL ESTATE TRANSFER - DECLARATION OF VALUE
Please read the instructions on the reverse side BEFORE completing and filing this form.
Part I - TO BE COMPLETED BY BUYER, SELLER OR AGENT
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SELLER:
SSN or FEIN:
Seller Address:
e-mail/phone:
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BUYER:
SSN or FEIN:
Buyer Address:
e-mail/phone:
Address of Property Conveyed:
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Date of Instrument:
Deed _1
Contract _ 2
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Legal Description:
Type of Sale (check all that apply):
Fulfillment of prior year(s) contract
Sale to/by Exempt Organization
Auction Sale
Corporate merger or reorganization
Purchase of adjoining land
Transfer of partial interest
Quit Claim Deed
Sale between family members or related parties
Foreclosure, forfeitures, or transfers arising from default; forced sale
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AG LAND
Was this a sale of
to:
Corporation
Trust
Alien
Non-Resident Alien
Limited Partnership
DECLARATION OF VALUE STATEMENT
1. Total Amount Paid
$____________________________
2. Amount Paid for Personal Property (see instructions)
$____________________________
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3. Amount Paid for Real Property Only (1 minus 2)
$____________________________
Contract Sale Information:
Down Payment $ _______________________
Interest Rate __________%
Monthly Payment $ _________________
Length of Contract ________________ years
Balloon Payment Date (if applicable)
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS FORM IS TRUE AND CORRECT AS
DETAILED ON THE BACK OF THIS FORM .
Printed Name:
Phone #:
Buyer or
Seller or
Agent or
Attorney
Signature
PART II - TO BE COMPLETED BY THE ASSESSOR
Classification of Property:
Res _4_
Com _5_
Ind _2_
Ag _1_
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Deeded Acres:
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OCC __________________________ TLA/GBA ____________________________ Tax District ________________________________________
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Primary Parcel Number
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( attach list of additional parcels)
Land
Building
Dwelling
Total
Full Assessed Value
January 1 of Year of Sale
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Effective Date of Form 09/30/12
Iowa Department of Revenue
57006a (03/23/12)
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