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BOE-502-AH(FRONT) REV.6 (8/04) <br />ASpfX <br />0 9 <br />oG�rY Of <br />O ICE OF ASSESS <br />DUNTY OF ALAMED) <br />ADMINISTRATION BUILDING, ROOM 145, 1221 OAK STREET <br />OAKLAND, CALIFORNIA 94612-4288 <br />(510) 272-3787 / FAX (510) 272-3803 <br />RON THOMSEN <br />CHANGE IN OWNERSHIP STATEMENT <br />REAL PROPERTY OR MANUFACTURED HOMES <br />SUBJECT TO LOCAL PROPERTY TAXES <br />CITY SAN LEANDRO <br />Attn: TARA PETERSPN <br />835 E 14TH ST <br />SAN LEANDRO, CA 94577 <br />ASSESSOR <br />ASSESSOR'S USE ONLY <br />REC'D.: <br />INPUT BY: <br />INPUT DATE: <br />FILE THIS STATEMENT BY: June 20, 2005 <br />EVENT DATE: June 29, 2004 NO.: 2004-294162 <br />APN: 79A-515-1-17 USE CODE: 4200 <br />PROPERTY ADDRESS: <br />1251 DOOLITTLE DR, SAN LEANDRO, CA 94577-2221 <br />LEGAL DESCRIPTION: <br />SELLER/TRANSFEROR: <br />COUNTRY LIFE INSURANCE COMPANY <br />ADDITIONAL APNS <br />PHONE NO. (8am - 5pm): <br />IMPORTANT NOTICE <br />The law requires any transferee acquiring an interest in real property or manufactured home subject to local property taxation, and <br />that is assessed by the Assessor, to file a Change of Ownership Statement with the County Recorder or Assessor. The Change of <br />Ownership Statement must be filed at the time of recording or, if the transfer is not recorded, within 45 days of the date of the change <br />in ownership, except that where the change in ownership has occurred by reason of death the statement shall be filed within 150 day; <br />after the date of death or, if the estate is probated, shall be filed at the time the inventory and appraisal is filed. The failure to file a <br />change in ownership statement within 45 days from the date of a written request by the Assessor results in a penalty of either: <br />(1) One hundred dollars ($100), or (2) 10 percent of the taxes applicable to the new base year value reflecting the change in ownershir <br />of the real property or manufactured home, whichever is greater, but not to exceed two thousand five hundred dollars ($2,500) if that <br />failure to file was not willful. This penalty will be added to the assessment roll and shall be collected like any other delinquent <br />property taxes, and be subject to the same penalties for nonpayment. <br />This notice is a written request from the Office of the Assessor for a Change of Ownership Statement. If you do not file this <br />statement, it will result in the assessment of a penalty. This statement will be held secret as required by section 481 of the Revenue <br />and Taxation Code. <br />The property which you acquired may be subject to a supplemental assessment in an amount to be determined by the Alameda County <br />Assessor. For further information on your supplemental roll obligation, please call the Alameda County Assessor at (510) 272-3787. <br />PART I: TRANSFER INFORMATION (Please answer all questions) <br />YES NO <br />❑ A. Is this transfer solely between husband -and wife?' (addition of a spouse, death of a spoLuse,-divorce fdttlement, etc.) <br />❑ d B. Is this transaction only a cdrrection of the name(s) of the person(s) holding title to the property (for example, a name change <br />upon marriage)? Please explain: <br />❑ 2" C. Is this document recorded to create, terminate, or reconvey a lender's interest in the property? <br />❑ Ei' D. Is this transaction recorded only as a requirement for financing purposes or to create, terminate, or reconvey a security interest <br />(e.g. cosigner)? Please explain: <br />❑ <br />C!� E. <br />Is this document recorded to substitute a trustee of a trust, mortgage, or other similar document? <br />❑ <br />la" F. <br />Did this transfer result in the creation of a joint tenancy in which the seller (transferor) remains as one of the joint tenants? <br />❑ <br />93" G. <br />Does this transfer return property to the person who created the joint tenancy (original transferor)? <br />H. <br />Is this transfer of property: <br />be by the transferor? <br />❑ <br />GIB <br />1. to a revocable trust that may revoked <br />❑ <br />E7' <br />2. to a trust that may be revoked by the Creator/Grantor who is also a joint tenant, and which names the other joint tenant(s) as <br />beneficiaries when the Creator/Grantor dies? <br />❑ <br />[� <br />3. to an irrevocable trust for the benefit of the ❑ Creator/Grantor and/or ❑ Grantor's spouse? <br />E](� <br />4. to an irrevocable trust from which the property reverts to the Creator/Grantor within 12 years? <br />❑ <br />[� I. <br />If this property is subject to a lease, is the remaining lease term 35 years or more including written options? <br />❑ <br />rJ. <br />Is this a transfer between parent(s) and child(ren)? ❑ Yes ❑ No or from grandparents(s) to grandchild(ren) ❑ Yes ❑ No <br />ClK. <br />Is this transaction to replace a principal residence by a person 55 years of age or older? <br />/ <br />Within the same county? ❑ Yes ❑ No <br />❑ <br />ER *L <br />Is this transaction to replace a principal residence by a person who is severely disabled as defined by Revenue and <br />/ Taxation Code section 69.5? Within the same county? E]Yes ElNo <br />❑ C� M. Did this transfer result from the death of a domestic partner currently registered with the California Secretary of State? <br />* If you checked yes to J, K, or L, you may qualify for a property tax reassessment exclusion, which may result in lower taxes on your <br />property. If you do not file a claim, it will result in the reassessment of the property. <br />Please provide any other information that would help the Assessor to understand the nature of the transfer. <br />IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS EXCEPT J,K OR L, PLEASE. SIGN AND DATE, <br />111-1009-027 (REV. 9/04) OTHERWISE COMPLETE THE REVERSE SIDE. <br />