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