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Fstatement to Tang Offleials
<br />Revised Fbrm —S 29 1965— EYSeeribed Dy elate Tu CommYdoner The Auguegne Co., brand ULnd, Nebr.
<br />f
<br />II t 87- 101238
<br />j Form It-MR This Statement is Confidential end AvailadAe
<br />(Revised) to Taztsg €S Only
<br />P This form, pursuant to Section 76-214 R. M S. 1943, as amended by the 75th Session of the Nebraska
<br />Legislature, must be completed by every Grantee and filed at the time each deed of real estate is !
<br />sented for recording, ! ii
<br />` a
<br />Donald W. Haggart Vernon Ray Bauer
<br />I. Grantor Eve2,M
<br />I hy _ _._ ran 7_ Ranpr
<br />;i
<br />Address- Island, Nebraska _ - Address ors, Nehracka --
<br />Type of Instrt mmt__ 4r —ranty Deed - - -- Date of Instrtmeat Ai,iguat _31), 196-7
<br />The Northwest Quarter (NWT) of Section Thirty Three (33)3 Township
<br />NebL al a ption Twelve (12) north, Range Nine (9) »test of the 6tb P.M,, Hall County,
<br />pting therefrom that portion conveyed to the State of Nebraska by Warranty
<br />Deed dated April 26, 1937 and recorded in the Office of peg ster of Deeds, Hall County,
<br />,Nebraska, in Deeds book #77 at page #92, and also excepting therefrom that portion deeded
<br />Ito Donald We Haggart and ibelyn C, Haggart, said deed dated September 8, 1967 and record-
<br />;ed in T the Office of the Register of Deeds, Hal'_ County, Nebraska, in Deeds book #1 at
<br />pa ,&,
<br />A. Total Consideration paid (cash, mortgages, property traded,
<br />assumed liabilities, etc.)
<br />B. Personal Property Included in Purchase
<br />C. Leases and Easements Included in Purchase __ --
<br />D. Other Items Included in Purchase _ --
<br />E. If Contract Sale, Total Interest & Carrying Charges
<br />N. Check Applicable Statement
<br />Sale or Transfer Between Relatives.
<br />(� Sale of Property in Connection with Foreclosure, Bankruptcy,,
<br />(_,j Condemnation or Other Such Legal Action.
<br />Purchase for different use than by Previous Owner
<br />_j (For Example — Agricultural to industrial Use)
<br />Q Other, Explain--San
<br />e A- ricult� rat
<br />I, the undersigned, having personal knowledge of this transaction, certify that the foregoing
<br />true and correct.
<br />Signature-.Z f .4�,,L lv -I 'Cu
<br />- �.nF,uu[y STOker -
<br />CER'T'IFICATION
<br />OFFICIAL USE: Book___.— Page
<br />Property Type: SU, MU, SS, MS, I, C, A _
<br />U Aorimhural: Total Aerprz Tr r im+ a Ae.-...s
<br />Type of Irrigation__
<br />Assessed Values -- - - - --
<br />Land
<br />Improvements $__ - _- - -- - --- ____ -, TOTAL 3- J
<br />Thus Sale should be used in a Sales Assessment Ratio Yes ❑ No ❑
<br />(Explain "No" answer on reverse side)
<br />County_
<br />County Identification
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