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f Pee a RP PhO PPV © WVEFTCIN VVINIEEEING UN CURIVI INSTRUCTIONS: http:// www.orps.state.ny.us or PHONE (518) 473-7222 FOR COUNTY USE ONLY PA) aie) y fess tn d C1. SWIS Code Es re OD ES ae ae Sees Oe Fitts ; iene C2. Date Deed Recorded ie, 3 BOARD OF REAL PROPERTY SERVICES | 8 a] oat | a c: BS cae _ Month Day Year iy C3. Book | te Pee if 8S Cone | C4. Page| : a eet Ene d | RP - 5217 RP-5217 Rey 3/97 PROPERTY INFORMATION | 1. Property 350 | Location STREET NUMBER Seal ay CITY OR TOWN VILLAGE ZIP CODE 2.Buyer | = LEGACY POT, | | Name LAST NAME / COMPANY FIRST NAME LAST NAME / COMPANY FIRST NAME | 3. Tax Indicate where future Tax Bills are to be sent Billing if other than buyer address (at bottom of form) | | Addréss LAST NAME / COMPANY FIRST NAME STREET NUMBER AND STREET NAME CITY OR TOWN | STATE | ZIP CODE | 4 . Indicate the number of Assessment (Only if Part of a Parcel) Check as they apply: i _~ | # of Parcels OR || Part of a Parcel [I Roll parcels transferred on the deed | 4A. Planning Board with Subdivision Authority Exists 5. Deed | | | | | 4B. Subdivision Approval was Required for Transfer LI Propert y moe ae Nraaaa x a OR 1 ! \ ACRES ; : ivisi 4C. Parcel Approved for Subdivision j Map with i Provided [| 6. Seller Rania |_ 220 G LAST NAME / COMPANY | FIRST NAME | LAST NAME / COMPANY FIRST NAME | 7. Check the box below which most accurately describes the use of the property at the time of sale: Check the boxes below as they apply: 8. Ownership Type is Condominium [| A || One Family Residential E Agricultural I Community Service 9. New Construction on Vacant Land [| ‘| 2 or 3 Family Residential F Commercial J Industrial 10A. Property Located within an Agricultural District [| Cc || Residential Vacant Land G Apartment K Public Service 10B. Buyer received a disclosure notice indicating Cl D ; | Non-Residential Vacant Land H Entertainment / Amusement L Forest that the property is in an Agricultural District i SALE INFORMATION i 15. Check one or more of these conditions as applicable to transfer: 11. Sale Contract Date A Sale Between Relatives or Former Relatives B Sale Between Related Companies or Partners in Business C One of the Buyers is also a Seller 12. Date of Sale / Transfer | | D Buyer or Seller is Government Agency or Lending Institution E Deed Type not Warranty or Bargain and Sale (Specify Below) F Sale of Fractional or Less than Fee Interest (Specify Below) am = . ns . . G Significant Change in Property Between Taxable Status and Sale Dates 13. Full Sale Price | ! \ ae ee ed : Yi VY - 0, 0 | H Sale of Business is Included in Sale Price (Full Sale Price is the total amount paid for the property including personal property. I |__| Other Unusual Factors Affecting Sale Price (Specify Below) This payment may be in the form of cash, other property or goods, or the assumption of J. None mortgages or other obligations.) Please round to the nearest whole dollar amount. 14. Indicate the value of personal ; ; ; ,o,0, 0 | property included in the sale 5 y ° r) | | ASSESSMENT INFORMATION - Data should reflect the latest Final Assessment Roll and Tax Bill | 16. Year of Assessment Roll from 17. Total Assessed Value (of all parcels in transfer) | which information taken 18. Property Class sy hig 33 cath‘y ntl L% Ba 7 20. Tax Map Identifier(s) / Roll identifier(s) (If more than four, attach sheet with additional identifier(s)) ry ent 4 4 ¢ thy te Yad at “PY mg | CERTIFICATION | knowledge and belief) and I understand that the making I certify that all of the items of information entered on this form are true and correct (to the best of my making and filing of false instruments. of any willful false statement of material fact herein will subject me to the provisions of the penal law relative to the BUYER’S ATTORNEY BUYER we Tom Ore a — ad FIRST NAME BUYER SIGNATUR 5 & wy ¢ eon gil CDF Li cumOS, i STREET NUMBER STREET NAME (AFTER SALE) AREA CODE TELEPHONE NUMBER iu Ph Baw wyey ae, (aie Tor) Oe CITY OR TOWN STATE CITY/TOWN ASSESSOR SELLER CORY oy Pkg i 4 : SELLER SIGNATURE; i