PT Form 976 (Revised 08/15) Minnesota Department of Revenue
Reconveyance of Portions of Forfeited Lands to the State of Minnesota
By a Governmental Subdivision
Under Minnesota Statutes, Section 282.01, Subdivision 1d
State Deed Tax Due: $1.65
Date: _________________
WHEREAS, pursuant to the statute now codified as Minnesota Statutes, Section 282.01, Subdivision 1a(e), the State of
Minnesota, on the _____________ day of __________________________, _______________, conveyed to
__________________________________, a governmental subdivision of the State of Minnesota (hereinafter “Governmental
Subdivision”), by state deed numbered ______________________, certain real property of which the real property described below
(hereinafter “Property”) is a portion, to be used for an authorized public use, and
WHEREAS, the Governmental Subdivision has either failed to put the Property to the public use for which it was conveyed,
or has abandoned the public use for which it was conveyed, and now desires to reconvey the Property under Minnesota Statutes,
Section 282.01, Subdivision 1d to the State of Minnesota, to be held in trust according to Minnesota Statutes, Section 281.25,
NOW THEREFORE, the Governmental Subdivision, pursuant to said laws, and pursuant to the duly adopted resolution of
its governing body number _______________________, dated _______________________, does hereby convey and quitclaim the
property in the County of _______________________, described as follows, together with all appurtenances thereunto belonging:
to the State of Minnesota, to be held in trust as provided by Minnesota Statutes, Section 281.25, upon like conditions and with like
effect as if the Property had not been conveyed to the Governmental Subdivision for a public use.
Check here if all or part of the described real property is Registered (Torrens)
__________________________________________________
(Name of Governmental Subdivision)
By:_______________________________________________
Signature Title Date
By:_______________________________________________
STATE OF MINNESOTA )
) ss.
County of )
The foregoing instrument was acknowledged before me this _________ day of _____________________, ____________,
by ________________________________________ and ________________________________________, respectively the
____________________________ and the _____________________________ of ______________________, a
____________________ under the laws of the State of Minnesota, on behalf of the ______________________.
