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Pk1 Nebra fund Claim- - for DQCUrnehtarv Stamp Tax ' FORM nebraska department :Attach a copy of the recorded deed %J 53 ■ of revenue :Read instructions an reverse side County Recorded Date Recorded Legal Description Hall 3-28-2012 Lot 9 Block 16 University place an additi- Name Hall County Register of Deeds Street or other Mailing Address 121:South Pine Street, Suite 6 CLAIMANTS NAME AND MAILING ADDRESS Name Grand island Abstract, EscEaw & Title Co. Street or other Mailing Address. P.O. Box 627 City State Zip Code City State Zip Code Grand Island. NE 68801 Grand Island NE 68802 1 Total amount of documentary stamp tax originally paid 2 Corrected amount of documentary stamp tax claimed due 3 Net amount of documentary stamp tax refund:claimed (line 1 minus line 2) 3 38 25 BASIS FOR REFUND CLAIM OF DOCUMENTARY STAMP TAX Deeds to the fthool distri t are exempt* =Exempt # Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is correct and complete. I certify t I have bome the ultimate financial responsibility for the payment of the amount stated above and I was not reimbursed or credited in any manner. sign a _ here signature of Claimant ~0 l 308-382-4651 Title Date Telephone FOR COUNTY REGISTER OF DEEDS RECOMMENDATION ONLY APPROVAL RECOMMENDED COMMENTS: R DISAPPROVAL RECOMMENDED Ej APPROVAL AS REVISED RECOMMENDED, SEE COMMENTS Date Rec ived y Register of Deeds Pr Register of Deeds Date FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY APPROVED COMMENTS: O DISAPPROVED APPROVED AS REVISED, SEE COMMENTS Date Received by Revenue Authorized Sionature 201202406 ISTER'OF DEEDS' NAME AND MAILING ADDRESS to the City of Grand Island, Hall County, Nebraska. Date A COPY OFTHE CHECK OR OTHER PROOF OF PAYMENT MUST BE ATTACHED TO THIS CLAIM TO BE FILED WITH THE COUNTY REGISTER OF DEEDS uthorimd try section M908 Rss moa • 5-148-1981 Rew S2005 supersedes $.1gg.1e81 Rev.9-te84