22 Total purchase price, including any liabilities assumed. . . . . . . ......................................................... 22 $
23 Was non-real property included in the purchase?
Yes No
(If Yes, enter dollar amount and attach itemized list.)
(see instructions) ..............................
23 $
24 Adjusted purchase price paid for real estate (line 22 minus line 23) ....................................................
24 $
25
If this transfer is exempt from the documentary stamp tax, list the exemption number ________________.
26 Is an affidavit as described in Neb. Rev.
Stat. § 76-2,141 required because the property is located within a county or other geographic area with an active air force ballistic missile field? (See Instructions)
Yes No
27 If yes, is the required affidavit attached to this filing? Yes No
8 Type of Deed Conservator Distribution Land Contract/Memo Partition Sheriff
Other ______________
________________
Bill of Sale Corrective Easement Lease Personal Rep. Trust/Trustee
Cemetery Death Certificate – Transfer on Death Executor Mineral Quit Claim Warranty
Single Family Industrial Mineral Interests-Nonproducing State Assessed
Multi-Family Agricultural Mineral Interests-Producing Exempt
Commercial Recreational
Mo. Day Yr.
13 Was the transfer between relatives, or if to a trustee, are the trustor and beneficiary relatives? (If Yes, check the appropriate box.)
Yes No Aunt or Uncle to Niece or Nephew Family Corp., Partnership, or LLC Self
Other ____________________
Brothers and Sisters Grandparents and Grandchild Spouse
Ex-spouse Parents and Child Step-parent and Step-child
14 What is the current market value of the real property? 15 Was the mortgage assumed? (If Yes, state the amount and interest rate.)
Yes No $ _____________________
___________ %
16 Does this conveyance divide a current parcel of land? 17 Was transfer through a real estate agent or a title company? (If Yes, include the name
of the agent or title company contact.)
Yes No
Yes _______________________ No
18 Address of Property 19 Name and Address of Person to Whom the Tax Statement Should be Sent
18a No address assigned 18b Vacant land
20 Legal Description (Attach additional pages, if needed.)
21 If agricultural, list total number of acres transferred in this transaction ___________________ .
1 County Name 2 County Number 3 Date of Sale/Transfer 4 Date of Deed
11 Was ownership transferred in full? (If No, explain the division.) 12 Was real estate purchased for same use? (If No, state the intended use.)
Yes
No ____________________________________________________________
Yes No ________________________________________
10 Type of Transfer Distribution Foreclosure Irrevocable Trust Revocable Trust Transfer on Death
Auction Easement Gift Life Estate Sale Trustee to Beneficiary
Court Decree Exchange Grantor Trust Partition Satisfaction of Contract Other (Explain) __________
FORM
521
The deed will not be recorded unless this statement is signed and items 1-27 are accurately completed.
Mo. Day Yr. Mo. Day Yr.
Nebraska Department of Revenue Authorized by Neb. Rev. Stat. §§ 76-214, 77-1327(2)
Form No. 96-269-2008 7-2024 Rev. Supersedes 96-269-2008 10-2020
Grantee — Retain a copy of this document for your records.
29 Value of Stamp or Exempt Number
$
28 Date Deed Recorded
Grantor’s Name (Seller) Grantee’s Name (Buyer)
Street or Other Mailing Address Street or Other Mailing Address
City State Zip Code City State Zip Code
Phone Number Phone Number Is the grantee a 501(c)(3) organization? Yes No
If Yes, is the grantee a 509(a) foundation? Yes No
Email Address Email Address
5 Grantor’s Name, Address, and Telephone (Please Print)
6 Grantee’s Name, Address, and Telephone (Please Print)
Real Estate Transfer Statement
• To be filed with the Register of Deeds. • Read instructions on reverse side.
• If additional space is needed, add an attachment and identify the applicable item number.
Print or Type Name of Grantee or Authorized Representative Phone Number
Signature of Grantee or Authorized Representative Title Date
Under penalties of law, I declare that I have examined this statement and that it is, to the best of my knowledge and belief, true, complete, and correct,
and that I am duly authorized to sign this statement.
Register of Deed’s Use Only For Dept. Use Only
30 Recording Data
(A) Status (B) Property Type (C)
Improved
Unimproved
IOLL
9 Was transfer part of IRS like-
kind exchange (I.R.C. § 1031
Exchange) by buyer or seller?
Buyer Seller No
Mobile Home
sign
here
7 Property Classification Number. Check one box in categories A and B. Check C if property is also a mobile home.
______________________
Select County
RESET
PRINT
Instructions
The register of deeds will not accept a deed for recording unless items 1 through 27 are properly completed and this Real Estate
Transfer Statement, Form 521, is signed.
Who Must File. Any grantee, or grantee’s authorized representative, who wishes to record a deed to real property must le Form 521.
When and Where to File. This Form 521 must be led with the register of deeds when a deed, land contract, memorandum of
contract, or a death certicate being recorded pursuant to a transfer on death deed is presented forrecording.
Specific Instructions
Grantee (Buyer)
• Note: An attachment may be added if additional space is needed for items 5, 6, and 20.
Items 1 and 2. Indicate the county where the property is located. If it is located in more than one county, indicate the county where
the transfer is being led. The county number can be found on the Department of Revenue website at revenue.nebraska.gov/PAD.
Item 4. The date of the deed is the date on which it was signed by the grantor, unless otherwise specied in the deed.
Items 5 and 6. Enter the complete name, address, and phone number of all of the grantors and grantees. A business address should
be used for business organizations such as corporations, trusts, and partnerships.
Item 7. Indicate the type of property being transferred. Check only one box in Categories A and B. “Improved” means land with a
building or a structure on it. “ IOLL” means improvement on leased land. Check C only if the property being transferred is a mobile home.
Item 8. Indicate the type of deed being led. Check all that apply.
Item 9. If the real estate being transfered was involved in a like-kind exchange under Internal Revenue Code § 1031, indicate all parties
involved in a 1031 exchange. Otherwise, choose No. If claiming an exemption, provide the recording ofce a copy of the exchange agreement.
Item 10. Indicate the type of transfer. Check all that apply.
Item 11. Indicate what property interests were transferred. If full ownership was not transferred, check “No” and explain.
Item 12. A “purchase for the same use” means a purchase with the same intended use of the property. A change in use can include,
for example, a vacant lot becoming a cemetery or an agricultural lot becoming a subdivision.
Item 13. Check the appropriate box to indicate if the transfer was between relatives.
Item 14. Indicate the current market value of the real property. Current market value is the purchase price which would be paid for
the property, based upon a sale between a willing buyer and a willing seller in the ordinary course of trade. If an easement is being
created or transferred, the current market value may be listed as $0 if no consideration has been given.
Item 15. Indicate whether the grantee assumed a mortgage as part of the purchase price. If a mortgage was assumed, check “Yes”
and indicate the dollar amount and interest rate. If no mortgage was assumed, check “No.”
Item 16. If this transfer divides the property into two or more parcels, check “Yes.” If this transfer does not divide or split the property,
check “No.”
Item 20. The legal description can be found from the deed of record or surveys of the real property.
Item 21. Indicate the total number of agricultural or horticultural acres included in the sale.
Item 22. Enter the total purchase price or consideration paid or to be paid, including cash, mortgages, property traded, assumed
liabilities, leases, easements, and personal property purchased.
Item 23. Enter the total dollar value of items which are included in the total purchase price, but are not considered a part of the real
property. For example, machinery, irrigation equipment, household goods, boat docks, etc. Check "Yes" if any non-real property is
included in the purchase price and attach an itemized list with a cost breakdown. The itemized list MUST be included with the dollar
amount of these items. If there are none of these items, check “No” and enter zero.
Item 25. The list of exemptions is available from the register of deeds or at revenue.nebraska.gov/PAD. Click on “Documentary
Stamp Tax” and “Documentary Stamp Tax Exemptions.” All deeds are presumed taxable unless it clearly appears on the face of the
deed or sufcient documentary proof is presented that the deed or transfer instrument is exempt.
Item 26. Nebraska Counties with active air force ballistic missile elds include: all of Banner, Cheyenne, Kimball, and Scotts Bluff Counties.
Deuel—All lands located south of Township 15 North, and west of Range 43 West using the Bureau of Land Management's Public
Lands Survey System.
Garden— All lands located south of Township 19 North, and west Range 43 West using the Bureau of Land Management's Public
Lands Survey System.
Morrill—All lands except those located north of Township 21 North using the Bureau of Land Management's Public Lands Survey System.
Sioux—All lands except those located north of Township 26 North, and east of Range 57 West using the Bureau of Land Management's
Public Lands Survey System.
Item 27. The afdavit required under this section shall be in substantially the following form: STATE OF NEBRASKA ) ) ss.
COUNTY OF ....... ) I, .................. (Purchaser), certify under penalty of perjury that I am not afliated with any foreign government
or nongovernment person determined to be a foreign adversary pursuant to 15 C.F.R. 7.4.
Authorized Signature. This Form 521 must be signed and dated by the grantee or the grantee’s authorized representative.
Documentary Stamp Tax. The current documentary stamp tax rate for transactions which are not exempt is $2.25 for every $1,000
of value being transferred.
Register of Deeds
The register of deeds will not record the deed if items 1 through 27 on this Form 521 have not been completed or the Form 521 has
not been signed by the grantee or authorized representative.
The register of deeds will complete items 28-30 at the time the deed or transfer instrument are recorded.
The register of deeds will forward this original Form 521 to the county assessor when items 1 through 28 are complete.
Retain a copy of this statement for your records.
