VILLAGE OF BEDFORD PARK

REAL ESTATE TRANSFER TAX

[   ]  DECLARATION                                        [    ] EXEMPTION

INSTRUCTIONS:

1. This form must be filled out completely, signed by at least one of the grantees (buyers), signed by at least one of the grantors (sellers), and presented to the Village Clerk, 6701 S. Archer, Bedford Park, Illinois, or other designated agent at the time of purchase of real estate transfer stamps as required by the Bedford Park Real Estate Transfer Tax Ordinance No. 96-977. The stamps must be affixed to the deed, and this form attached, when the title is recorded.

2. The full and actual amount of consideration of the transaction is the amount upon which the tax is to be computed. Both the full actual consideration of the transaction and the amount of the tax stamps required must be stated on the declaration.

3. An inspection of the premises, prior to closing, must be completed by the Village Building Inspector so to ensure that there is compliance with all building code ordinances. Copies of said ordinances are attached for your convenience.

4. For additional information, please call:

            Village Hall 708-458-2067,  Monday---Friday, 8:30----4:30 P.M.

Address of Property______________________________________________________

Permanent Property Index number___________________________________________

Date of Deed_____________________________________________________________

Type of Deed_____________________________________________________________

Note:  The Village of Bedford Park Real Estate Transfer Tax Ordinance Specifically exempts certain transactions from taxation. These exemptions are enumerated in section 2D of the ordinance. To claim one of the exemptions complete the appropriate blanks below:

I herby declare that this transaction is exempt from taxation under the Bedford Park Real estate Tax Ordinance No. 96-977 by paragraph (s) ______________ of section 2D of said ordinance.

Details of exemption claimed: (explain) ________________________________________________________________________________

________________________________________________________________________________

We hereby declare the full and actual consideration and above facts contained in this declaration

to be true and correct.

Grantor:  (seller)                        (please print)

_______________       __________________________________       ______________________

    name                                          address                                                        zip code

Signature__________________________________________            Date__________________

Grantee:           (buyer)                            (please print)

____________________________           _____________________________     _____________

      name                                                          address                                                 zip code

Signature:___________________________           Date signed_____________________

                         buyer or agent