NUECES CANYON C.I.S.D. TAX OFFICE

P.O. BOX 73

BARKSDALE, TX. 78828

830-234-3480, FAX 830-234-3435

REQUEST FOR STATEMENT OF NO TAXES DUE AND FOR TAXES TO BE PAID INTO ESCROW FOR THE 2010 TAX YEAR

All information on this form must be complete and legible or it will be returned for correction. This is not a tax certificate and the statement applies only to those taxes collected by the Nueces Canyon C.I.S.D. Tax Office.

Name (please print) Date of Sale

Address (statement will be mailed to this address) Phone# ( )

Manufactured Home Description: Serial/Label #

Current Location: (Ex: Lot 1 Blk. 2 City of or Subdivision or physical address)

Buyer Information: Buyer’s Name and Address

Home moving to: New Location City State County

I, the undersigned, request confirmation that no taxes are due on the above described manufactured home and that the estimated taxes for the 2009 tax year have been paid into escrow. I have paid $10.00 to the Nueces Canyon C.I.S.D. tax collector for a tax certificate that certifies there are no taxes due on said manufactured home for any prior tax year and it is attached hereto. I understand that this document applies only to taxes collected by the Nueces Canyon C.I.S.D Tax Office.

Signature______Date______

Property ID#:

Current Owner’s Name and Address: (Owner as shown on Tax Roll as of date of issuance)

PROPERTY AND PAYMENT IFORMATION

Payee: (If different from above)

Manufactured Home Description:

Estimated tax levy $______Amount paid into escrow: $______Receipt #______

{ } Property is NOT taxable for the above tax year. Mobil home was removed from tax rolls effective tax year: ______

CONFIRMATION OF NO TAXES DUE AND ESTIMATED TAXES PAID INTO ESCROW FOR THE 2010 TAX YEAR

I confirm that there are no delinquent taxes due on the above described manufactured home as show by the tax certificate attached hereto and made part hereof for all pertinent purposes. I also confirm that the estimated taxes for the above year have been paid into escrow. (Note: This document is void unless a tax certificate is attached.)

X______

Tax Collector’s Signature Date