Affidavit For Exemption Under
Section 253 of the Tax Law

Affidavit For Exemption Under Section 253 of the Tax Law

State of )
County of )

being duly sworn deposes and says that I am the of the hereinafter described mortgage, and is familiar with the facts set forth herein.

That a certain mortgage made by to in the amount of , which mortgage is dated is being duly recorded simultaneously herewith in the office of the of the County of ; that the mortgagee named above is a natural person or persons and the mortgaged premises consists of real property improved by a structure containing a six residential dwelling or less each with separate cooking facilities. That pursuant to Section 253 1-A(A) the mortgage submitted herewith for recording is exempt from the special additional mortgage tax, wherefore, deponent respectfully requests that the mortgage herewith tendered for recording be declared exempt from the additional mortgage tax.

Sworn to before me
This day of ,