Affidavit of Non-Foreign Status Template

Date: [Date]

To: [Buyer / Transferee Full Name]
Address: [Address]

From: [Seller / Transferor Full Name]
Address: [Address]

1. Transferor Information

Transferor Name: [Full Legal Name]
Taxpayer Identification Number: [SSN / EIN / ITIN]
Home Address or Office Address: [Full Address]

If the transferor is an entity, entity type:

[Corporation / LLC / Partnership / Trust / Estate / Other]

2. Property Information

Property Address: [Property Address]
City, State, ZIP Code: [City, State, ZIP Code]

Legal Description, if applicable:

[Insert legal description]

Closing or transfer date, if known:

[Date]

3. Certification of Non-Foreign Status

The undersigned transferor certifies that the transferor is not a foreign person within the meaning of Internal Revenue Code section 1445.

This certification is made for the purpose of informing the transferee that withholding of tax is not required under FIRPTA with respect to the transfer of the U.S. real property interest described above.

4. Additional Transferor Statement

The transferor further states that:

the name shown in this certification is the transferor’s correct legal name;
the taxpayer identification number shown in this certification is the transferor’s correct U.S. taxpayer identification number;
the address shown in this certification is the transferor’s correct home address or office address.

5. Optional Transaction Reference

This certification relates to the following agreement or transaction, if applicable:

Purchase Agreement Date: [Date]
Buyer Name: [Full Name]
Seller Name: [Full Name]
Escrow or Closing Reference Number: [Number]

6. Optional Entity Clarification

If the transferor is signing on behalf of an entity, the signer states:

Name of Entity: [Entity Name]
Signer Name: [Full Name]
Title or Authority: [Title]

7. Penalties of Perjury Statement

Under penalties of perjury, I declare that I have examined this certification and that, to the best of my knowledge and belief, it is true, correct, and complete.

8. Signature

Transferor Signature: __________________________
Name: [Full Name]
Date: [Date]

If signed for an entity:

Authorized Signer Signature: __________________________
Name: [Full Name]
Title: [Title]
Date: [Date]

9. Optional Buyer Acknowledgment

Buyer / Transferee Acknowledgment: __________________________
Name: [Full Name]
Date: [Date]

10. Optional Notary Acknowledgment

State of [State]
County of [County]

On this [Day] of [Month], [Year], before me, the undersigned notary public, personally appeared [Name of Signer], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that they executed the same for the purposes stated herein.

Notary Public Signature: __________________________
Name: [Notary Name]
My Commission Expires: [Date]

11. Optional Closing File Note

Closing Agent / Escrow Holder: [Name]
File Number: [Number]
Retention Note: Buyer or closing file should retain this certification with the transaction records. The regulation says the transferee must generally retain the certification until the end of the fifth taxable year following the year of transfer.