Michigan Department of Treasury
L-4258 (Rev. 3/95)
REAL ESTATE TRANSFER TAX VALUATION AFFIDAVIT
This form is issued under authority of P.A. 134 of 1966 and 330 of 1993 as amended.
This form must be filed when you choose not to enter the amount paid for real estate on the deed. It is not necessary when the amount paid is entered on the deed. This form must be completed and signed by either the seller or his/her authorized agent.
1. County of Property
3. Seller's Name and Mailing Address
2. City or Township of Property
4. Purchaser's Name and Mailing Address
5. Type and Date of Document
DeedDate:
10. If consideration is less than market value, state market value.
6. Cash Payment
$
8. Amount of Mortgage/Land Contract
$
11. Total Consideration (Add lines 6&8)
7.Amount of County Tax
9.Amount of State Tax
12. Total Revenue Stamps
13. Legal Description of Real Estate Transferred
I certify that the information above is true and complete to the best of my knowledge.
If signer is other than the seller, print name and title.
Subscribed and sworn to me:
Notary Public
State of Michigan; County of:
My commission expires on: