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PLEASE TYPE OR PRESS FIRMLY WHEN WRITING ON FORM
.iNSTRUCTIONS: hep://www.orps.state.ny.us or PHONE (518) 473-7222
REAL PROP~ERTY TRANSFER REPORT
STATE OF NEW YORK
STATE BOARD OF REAL PROPERTY SERVICES
RP -5217
VILLAGE Zip CODE
2, Buyer
LAST NAME / COMPANY
3. Tax Indicate where future Tax Bills are to be sent
Bgllng if other than buyer address (st bottom of form
Address
STREET NUMBER AND STREET NAME
4. Indicate the number of Assessment
Roll parcels transferred on the deed
LAST NAME / COMPANY
CITY OR TOWN
, (-' I #of Parcels OR ~ Part ofaParcel
5. Deed
Property [ FRONTFEET I X l DEPTH I OR I , ,
ACRES
Size
Name LAST NAME / COMPANY
(Only if Part of a Parcel) Check as they apply:
4A. Planning Board with Subdivision Authority Exists
4B. Subdivision Approval was Required for Transfer
4C. Parcel Approved for Subdivision with Map Provided
FIRST NAME
;T NAME / COMPANY ~AME
7. Check the box below which most accurately describes the use of the property at the time of sale:
A~ One Family Residential
B ~ 2 or~J:amiry Residential
C ~-sidenRal Vacant Land
.~D~.~~] Non-Residential Vacant Land
Is=
11. Sale Co~ra~ Date
12. Data of Sale / Transfer
Agricultural I [~ Community Service
Commercial ~ ~ Industrial
Entertainment/Amusement ~[~ Forest
Month' Day Year
Month Day Year
13. Full Sale Price I I I I I ~ I ~ I ~ 0 I 0 I
(Full Sale Pri~¢ is the total amount paid for the property including personal property.
This payment may be in the form of cash, other property or goods, or the assumption of
mortgages or other obligations.) P/easeroundtothenearestwholedollaramount.
14.1ndicata the value of personal I I I I I'*~- I ~' 0 I 0 I
Check the boxes below a~ they apply:
8, Ownership Type is Condominium []
9. New Construction on Vacant Land []
10A. Property Located within an Agricultural District []
t0B. Buyer received a disclosure notice indicating []
that the property is in an Agricultural District
15. Check one or more of these condgions as a~licable to transfer:
Sale Between Relatives or Fo~r~er Relatives
lelated Companies or Partners in Business
C One of the Buyers is also a Seller
D Buyer or Seller is Government Agency or Lending rnstitugon
E Deed Type not Warranty or Bargain and Sale (Speclfy Below)
F Sale of Fractional or Less than Fee Interest (Specify Below)
Significant Change in Property Batween Taxable Status and Sale Dates
Sale of Business is Included in Sale Price
Other Unusual Factors Affecting Sale Price {Specify Below)
None
16. Year of Assessment Roll from I i / I 17. Total Assessed Value (of all pa=is in transfer)
which information taken
18. Property Ciass I / , h, , I r 19. ~hool District Name I
20. Tax Map Ider~fler{s) / Roll Idd~tifier(s) {If more than four, attach sheet with additional identifier(s)} ¢
I qX.., o t,-, ,..,0 - ,co - 2 2..- I I ? ·
j.. BUYER
.~-. I l'/. ~.~' ~ ~'-~: .....
SELLER
BUYER'S ATTORNEY
AREA CODE