1. The liability for the payment of this tax shall be borne by the Grantee (Buyer) or Lessee.

2. This form must be filled out completely, signed by the grantee (Buyer or Buyer’s Agent) or Lessee (Lessee’s Agent), and presented to the Finance Department, 50 South Emerson Street, Mount Prospect, IL 60056, at the time of purchase of the real estate transfer tax stamps as required by the Village of Mount Prospect Real Estate Transfer Tax Ordinance. If a signed copy of the Illinois Declarationform does not accompany this form at the time the transfer stamp is purchased, a legible copy of the executed sales contract must be provided. If the transaction is exempt, a copy of the executed deed must be attached. The stamps must be affixed to the deed, and this form attached, when the title is recorded. NOTE: The Village is not responsible for lost or stolen real estate transfer tax stamps.

3. The full 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 required must be stated on the declaration.

4. If the Illinois Declaration form is not presented at the time the stamp is purchased, then a signed copy of the Illinois Declaration form must be sent to the Finance Department, pursuant to Section 8.810 of the Ordinance, by the Grantee (Buyer) within ten days after delivery of the deed or assignment of interest.

5. All water and sewer charges and refuse bills attributable to the property, past due and current, and any other amounts due the Village by the current property owner must be paid prior to issuance of the tax stamp.

6. Long-term leases or similar contracts for a term of more than thirty years are subject to the tax.

7. A partial rebate of this tax is available to certain qualified individuals who previously paid the tax on a principal residence within the Village. Please see Section 8.804 of the Ordinance for further details.

8. For additional information, please contact the Finance Department at (847) 392-6000, Monday through Friday, 8:30 a.m. to 5:00 p.m.

AMOUNT OF TAX ($3.00 per $1,000 or fraction thereof of full value consideration) $