CERTIFICATE OF NON FOREIGN STATUS
(FIRPTA AFFIDAVIT)
Section 1445 of the Internal Revenue Code provides that a transferee (buyer) of a U.S. real property interest
must withhold tax if the transferor (seller) is a foreign person.
To inform _______________________________________________________________ (the “Transferee”)
that withholding of tax is not required upon the disposition of a U.S. real property interest by (the “Transferor”),
the undersigned hereby certifies the following on behalf of the Transferor:
1. That the Transferor is the owner of the following described property, to wit:
Block: ___________ Lot: _________ County:_____________________ State:_______
Premises:___________________________________________________________
2. The Transferor is not a non-resident alien for purposes of the U.S. income taxation (as such term is defined in
the Internal Revenue Code and Income Tax Regulations).
3. The Transferor’s U.S. taxpayer identification number (Social Security Number) is _____________________
4. The Transferor’s address is
________________________________________________________________________
________________________________________________________________________
5. The Transferor understands that this certification be disclosed to the Internal Revenue Service by the
Transferee and that any false statement contained herein could be punished by fine, imprisonment or both.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS CERTIFICATION
AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE, CORRECT AND COMPLETE,
AND I FURTHER DECLARE THAT I HAVE AUTHORITY TO SIGN THIS DOCUMENT ON BEHALF OF
THE TRANSFEROR.
Signed and Sworn before me on this By: ____________________________________
______ day of _____________, 20 _____
By: ____________________________________
___________________________________
Notary Public
By: ____________________________________
By: ____________________________________
