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Nebrasl~a, f1pN d Claim <br />Pk <br />ebraska <br />i for Documentary Stam <br />Tax <br />dn <br />FORM <br />/ <br />p <br />r <br />epertment .Attach a copy of the recorded deed l <br />of revenue 'Read Instructions on reverse side <br />L9 <br /> <br />County Recorded <br />Date Recorded Legal Description <br />Hall <br />3-28-2012 Lot 11, Block 16, Universitv <br />Place, an Addition <br />Deed Book <br />Deed Page to the City of Grand Island, <br />Hall County, <br />201202407 Nebraska. <br />REGISTER OF DEEDS' NAME AND MAILING ADDRESS <br />CLAIMANTS NAME AND MAILING ADDRESS <br />Name <br />Name - <br />- . <br />Hall County Register of Deeds <br />Grand Island Abstract, Escrow & Title Co. <br />Street or Other Ma iing Address <br />Street or Other Mating Address <br />121 South Pine-Street, Suite 6 <br />P.O. Box 627 <br />City State Zip Code <br />city state <br />Zip Code <br />Grand Island NE'. 68801 <br />Grand Island NE <br />68802 <br />1 Total amount of documentary stamp tax originally paid <br />1 <br />X15 00 <br /> <br />2 Corrected amount of documentary stamp tax claimed due <br />. <br /> <br /> <br />2 <br />0 00 <br />3 Net amount of documentary Stamp tax refund 'ciairrted (line 1 minus line 2) <br />3 <br />315 00 <br />BASIS FOR REFUND CLAIM OF DOCUMENTARY STAMP TAX <br />Deeds to the school district are exempt-Exempt .112 <br />Under penalties of perjury, I declare that I have ommined this claim, and to the best of my knowledge and belief. It is correct and complete. I csrtffy <br />that I have borne the ultimate financial responsibility for the payment of the amount stated above and I was not reimbursed or credited In any manner. <br />sign <br />here signature ofClal retie _308-382-4651 <br />Gate Telephone <br />FOR COUNTY REGISTER OF DEEDS RECOMMENDATION ONLY <br />APPROVAL RECOMMENDED COMMENTS: <br />FIDISAPPROVAL RECOMMENDED <br />E] APPROVAL AS REVISED <br />RECOMMENDED, SEE COMMENTS <br />0 -511 I ZO 1 Z Gym ( ~s / / ~ ? <br />Date Re6elvedfby Register of Deeds / Register of Deeds Date <br />FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY <br />K APPROVED COMMENTS: <br />DISAPPROVED <br />APPROVED AS REVISED, <br />SEE COMM NTS 7AV <br />Z <br />Date Re Revenue AuthoiEia SLgnature <br />Dat~ O -z? <br />A COPY OF THE CHECK OR OTHER PROOF OF PAYMENT MUST BE ATTACHED TO THIS CLAIM <br />TO BE FILED WITH THE COUNTY REGISTER OF DEEDS <br />ufhorved by Section Mew RSs mm <br />• 6-148-1981 Rev 5-2W5 supersedes 6-148-1881 Rev. 9-19M <br />