Document No. < - pause>	Date Recorded: < - pause>

STATEMENT OF TAX DUE AND REQUEST THAT TAX NOT BE MADE A PART OF THE

PERMANENT RECORD IN THE OFFICE OF THE COUNTY RECORDER.

To: County Recorder,

Request is hereby made in accordance with the provisions of the Documentary Transfer Tax Act that the amount of the tax due not be shown on the original document which names:

Grantor or Lessor

Grantee or Lessee

Property described in the accompanying document is located in

City or Unincorporated Area

The amount of tax due on the accompanying document is $

computed on full value of property conveyed;

computed on full value of property conveyed;

Signature of Declarant or Agent

Firm Name

Note: After the permanent record is made, this form will be affixed to conveying document and returned with it.

Document No

Granite Software

2010-04-26

Granite Software