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<br />0../09/2008 WED 3:05 FAX 40201 5993 SONE~~~;~;TYBAS't & TAX 200803381 ~a02/002
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<br />T08:F!W=O Real Estate Transfer State~PV FORM
<br />~~ ~bS;EP. · Read imrtrl.lCtlonson reversellide .~ I 521
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<br />I THE Dfl!D WILL NOT BE Rl;;CORDED UNLESS THIS STATEMENT IS SlGNED 'AND LINES 1.2S ARE ACCllRATEL YOOMPLETED]
<br />1 COI.Jnt'l H'1t 2-C;;;--N;~ter '--r3Q;te '71\1 I... u --=-:14i>ate of ~ f Il .
<br />Me. Day ~r. ~MO. --42--D~~Y',.Q3
<br />[i~ntor'~ Name, Address, and ele ne _(Please 6 Gnntee's Name,. Address, a!\d Tel!p'hane (Please Print) I
<br />Grantor'll N!ll1e (S~leri Grillltees N~m~ (~)~
<br />EJ..c~ I r1 ~, (11'1t'uJ.:e.:<:~llOq 9 PYl .:50'i!.e. j t ~ a. '" ~ C"\
<br />Street ~. OtI:er MiIInn? Address Strllet or otha' M3illro\i A.r.'.dres~
<br />"1{) J,g, R Cp6h ~d o._~t l/: 3b" 15 (J, loTt-t g
<br />City st.lte \ . State I . l!l " Q ll~ Code
<br />I.!.~ O..Jhy" k)"h-r".J:zm... ,~'VQs- v\&.. ~~___
<br />~~ TelePhon~ul\".ber . ~
<br />l~.r;583 &fJ<J(q. __ . .O_..__~___fl7 g-- 2.-r ___'_j
<br />17 PROF'ERTY ClASSIFICA~NUMB.ER.._9'eck on~_~o)( In ~.t:egorl!!~d 8. ~eck C a/$() If prop<<trty Is mobile home.
<br />r (A) St:abJ1i j (8) Property' Type (C) _
<br />'- (i~lmprOvtd {l) SI1gle Famllv (~}D Incwst'il! (5)'=f~t. onii-(f1) 0 Mlnerallrter!$lS' (9) [] State A$;essed (1) 0 Mabie Home
<br />(2)0 Unimproved (l) Multl-famllv (5) 0 Agr1CUltllr~1 (7) 0 Mi~e~ !nterests- Pllldudng (10) 0 Exempt
<br />(30 tell (3)0 Commtrdll tlOWo'Ju<lnl}
<br />'Slyr;e rA 0.;;-- ----.-----..------,---..
<br />iJ W,'ranty 0 Sherlff 0 ExeClJtcr 0 t~lneral
<br />o QUit C.1aim 0 Consermor 0 P3rtid<ln 0 Trust
<br />10 TyPe Of Tra~~r
<br />C $;Jle DAu,1:'O~_~~.:~ch~nge __.0 Foreclosure 0 Satlofectlon orC.ontracl 0 Ute EState 0 Other(e~~ld~l)-~--..:
<br />11 Ownership' Tr~.,S1'e,,~d in F~II (If No, e;(p.ain dlv'sion) 111 W~s real est~le ~urchased for same U~? (If :\0, sta:e Intended use)
<br />~~,fIJ YES ~~--==--=-.u~__.__.:....._____:_L~ 0 NO __--====
<br />.... VY3$ sale OOtween ;e"",:ves? (lr"Yes, check a:lPl'~pliate ~cx)
<br />1J Y=S 0 NO 0 spciu~ pc Pu-en~ 8IlC C!ll1d 0 FamUy Corporation or f'armel'S~ip
<br />o Grandparents and Grand,Md 0 6rothers and Sisters 0 A~nt or lJnde to NIeot or Nephew 0 Other____
<br />14 ~a~~~;1 e'ht'ij!)ran"'~rted ~ nominal conslCl!I'atbt" w~~t:5 the current:-';:;;OOit 115 '0$ ;:srtg~ge~SU;;;d? U Yes, state arnoun;;.d I~ter!st rate. %
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<br />16 DOeS this c::Xrv1?';~~i\lI~~'!;,urrent part!1 or lane? 11] ..---- ~.._.' Was S~le throu9h a re~1 emt" ~ent? (it Yes, nam~ of ~ge~t)--
<br />_--..9. YES . ~NO i OYES_ ~ NO__.~:_
<br />18 Address of p~. 7 () J ~ s 9(jt-!J R c/
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<br />WCt!cl1 'R I\J t-f ~C{S~. f tLlx.... e:
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<br />.. "''' -..., 1+ -r.,. 4(:,( 0{' I t1. ,,4 t. ~ IS"'" rf. e- R. ,:,s.l..iTr 6 n e h u.. '" c V < cI -
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<br />~ ~+{ ( lS:o. o. .f?e.e..-f at -1-.-1, e.. I'\.D -rthe.rLy TWb hu...r-c.\..r e.cl Twe..n-t.y t-=, V~b).c""
<br />~ '1 t+. "'-t"c1i,eo.s+ ~,,~-<->( of'/;- h... M>(~ -os t. ~'t1..-<-~ jJ€.L tJE i' ,~
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<br />:: TO~~~=:::'~:",~ ~~~~~~)C~~~~hl~~~~~ ,f;~ +~~~~~
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<br />23 Was n~reaJ property Included In purchase? 0 YES 0 NO (if Yes, enter amount and attach Itemized list) . .~3 $ I
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<br />~u..."ted purdlase price paid f')r real estate (lIne 22 mi'lUs "!:1~.11l. ...........,....,................ $ ____--L_
<br />Under penaltle$ of "w, ! dec~'e that [ hal1e emr.lnej this ~.temel1t a,'\(j that It is, to IMl' i:>e~ of m'{ kMWi<ldS' and beUef, true
<br />an;! correct, ~nd ttl.t I am d~~{ arrcn to sign l~IS statement
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<br />25 i V\ 'f:> E- ~( ~ 'rtI ~ e. \i\.... 3ce Je 3 ~a1b
<br />sign to Type a~ of Gra~~g:n;~~~_ ~e~pn:e ~u:___
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<br />'here ure ~ Gra~~ or Authcnzed n!,ell atlve _ TIt!e _.____________ _~Jte L~:_~ 3
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<br />_.__..~GIST1! OF DEEO~' USE ONL y .~ _____ :FOR ,!~R USE ONI.'I
<br />21 Date Ot~ecordl3 tJ...B i \lalu~ ~scamp or E.<=pt N~rn~ /28 ~eC 800~ ..,,-T2!!oEed p~ :r-.o .
<br />Mo. Day - Yr $ CYI-fy; fT r'!6:=lo(c1u'? I ~S-rf....$- 1..________
<br />Ne!lnloloo DopMment of ~rlV J.s_.m..t Ik T""""'" lult1cn,,,, ty So<:tloOl 7~'lj.. T7-;327, ~.~s. 1943
<br />Form Nt. 2.1.6-67 Ro.. 12.1)(1 ;'Jpersed<. 2'1_6.67 R..... H4
<br />fl NEBAASKA. DEPARTMENT OF REVENUE - WhIte CODY
<br />'6.3 pfln/l!d willi soy 11'1* C/I ~ p.-.per
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<br />19 Nome an1 Addre$S of Fer-on to Whom n; stlltement Snould be ~nt
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<br />COUNTY ASSESSQ:l- Canary ..no PI.,k CcIJ!~
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<br />GRAN""EE - Gcldemod Copy
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