Nebraska Quitclaim Deed Form 1

Real Estate Transfer Statement
• To be filed with the Register of Deeds.
• Read instructions on reverse side.
The deed will not be recorded unless this statement is signed and items 1-25 are accurately completed.
1 County Name
2 County Number
3 Date of Sale
4 Date of Deed
Mo. Day Yr. Select County & County Number
Mo. Day Yr. 5Grantor’s Name, Address, and Telephone (Please Print)
6 Grantee’s Name, Address, and Telephone (Please Print)
Grantor’s Name (Seller)
Grantee’s Name (Buyer)
Street or Other Mailing Address
Street or Other Mailing Address
Zip Code
Zip Code
State Assessed
Mobile Home
Telephone Number
Telephone Number
( )
( )
7 Property Classification Number. Check one box in categories A and B. Check C if property is also a mobile home.
(A) Status
(B) Property Type
Multi-FamilyAgriculturalMineral Interests-Producing Exempt
8 Type of Deed
Single Family
Mineral Interests-Nonproducing
Land Contract
Personal Rep.
Bill of Sale
Joint Tenancy
Quit Claim
Transfer on Death
9 Was the property purchased as part of
an IRS like-kind exchange?
(IRC § 1031Exchange)
Yes No
10 Type of Transfer
Revocable Trust
Court Decree
Satisfaction of Contract
Joint Tenancy
Life Estate
Irrevocable Trust
Transfer on Death
Other (Explain.) ___________
11 Was ownership transferred in full? (If No, explain the division.)
12 Was real estate purchased for same use? (If No, state the intended use.)
NO ____________________________________________________________
NO ________________________________________
13 Was the transfer between relatives, or if to a trustee, are the trustor and beneficiary relatives? (If Yes, check the appropriate box.)
Parents and Child
Brothers and Sisters
Family Corp., Partnership or LLC
Other ____________________
Grandparents and Grandchild
Step-parent and Step-child
Aunt or Uncle to Niece or Nephew
15 Was the mortgage assumed? (If Yes, state the amount and interest rate.)
14 What is the current market value of the real property?
$______________________ ____________ %
17 Was transfer through a real estate agent? (If Yes, include the name of the agent.)
16 Does this conveyance divide a current parcel of land?
YESNO __________________________________________________
19 Name and Address of Person to Whom the Tax Statement Should be Sent
18 Address of Property
20 Legal Description
21 If agricultural, list total number of acres ___________________ .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
23Was nonreal property included in the purchase?
NO (If Yes, enter amount and attach itemized list.) . . 23
24Adjusted purchase price paid for real estate (line 22 minus line 23) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
22Total purchase price, including any liabilities assumed
25If this transfer is exempt from the documentary stamp tax, list the exemption number ___________________ .
Under penalties of law, I declare that I have examined this statement and that it is, to the best of my knowledge and belief, true, complete, and
correct, and that I am duly authorized to sign this statement.
Print or Type Name of Grantee or Authorized Representative
Telephone Number
Signature of Grantee or Authorized Representative
26 Date Deed Recorded
Register of Deeds’ Use Only
27 Value of Stamp or Exempt Number
28 Deed Book
For Dept. Use Only
29 Deed Page
Mo. Day Yr. Nebraska Department of Revenue
Form No. 96-269-2008 Rev. 7-2013 Supersedes 96-269-2008 Rev. 8-2011
Grantee — Retain a copy of this document for your records.
Authorized by Neb. Rev. Stat. §§ 76-214, 77-1327
The Register of Deeds will not accept a deed for recording unless items 1 through 25 are properly completed and this Real
Estate Transfer Statement, Form 521, is signed.
Who Must File. Any grantee, or grantee’s authorized representative, who wishes to record a deed to real property must
file Form 521. A land contract or memorandum of contract requires a completed Form 521, which is not subject to the
documentary stamp tax until the deed is presented for recording.
When and Where to File. Form 521 must be filed with the Register of Deeds when the deed or land contract or memorandum
of contract is presented for recording.
Specific Instructions
Grantee (Buyer)
Items 1 and 2. Indicate the county where the property is located. If it is located in more than one county, indicate the
county where the transfer is being filed. The county number can be found on the Department of Revenue website at
Item 4. The date of the deed is the date on which it was signed by the grantor, unless otherwise specified in the deed.
Items 5 and 6. Enter the complete name, address, and telephone number of the grantor and grantee. A business address
should be used for business organizations such as corporations, trusts, and partnerships.
Item 7. Indicate the type of property being transferred. Check only one box in Categories A and B. "IOLL" means improvement
on leased land. Check C only if the property being transferred is a mobile home.
Item 8. Indicate the type of deed being filed. Check only one box.
Item 9. Indicate whether the real estate transfer is a like-kind exchange under Internal Revenue Code § 1031.
Item 11. Indicate what property interests were transferred. If full ownership was not transferred, check “No” and explain.
Item 10. Indicate the type of transfer. Check only one box.
Item 12. A “purchase for the same use” means a purchase with the same intended use of the property. A change in use can
include, for example, a vacant lot becoming a cemetery or an agricultural lot becoming a subdivision.
Item 13. Check the appropriate box to indicate if the transfer was between relatives.
Item 14. Indicate the current market value of the real property. Current market value is the purchase price which would be
paid for the property, based upon a sale between a willing buyer and a willing seller in the ordinary course of trade.
Item 15. Indicate whether the buyer assumed a mortgage as part of the purchase price. If a mortgage was assumed, check
“Yes” and indicate the dollar amount and interest rate. If no mortgage was assumed, check “No.”
Item 16. If this transfer divides the property into two or more parcels, check “Yes.” If this transfer does not divide or split
the property, check “No.”
Item 20. The legal description can be found in the deed or the abstract of the real property.
Item 21. Indicate the total number of agricultural or horticultural acres included in the sale.
Item 22. Enter the total purchase price or consideration paid or to be paid, including cash, mortgages, property traded,
assumed liabilities, leases, easements, and personal property purchased.
Item 23. Enter the total dollar value of items which are included in the total purchase price, but are not considered a part of
the real property. If there are none of these items, check “No” and enter zero.
Item 25. The list of exemptions is available from the Register of Deeds or at under “Featured
Information.” Click on “Documentary Stamp Tax” then click on “Documentary Stamp Tax Exemptions Chart.”
Authorized Signature. Form 521 must be signed and dated by the grantee or the grantee’s authorized representative.
Register of Deeds
The Register of Deeds will not record the deed if items 1 through 25 on Form 521 have not been completed or the Form 521
has not been signed by the grantee or authorized representative.
The Register of Deeds will complete items 26 through 29 at the time the deed is recorded.
The Register of Deeds will forward Form 521 to the county assessor when items 1 through 29 are complete.
Please retain a copy of this statement for your records.