Fill and Sign the Certification No Information Reporting Form

File # _________________ CERTIFICATION FOR NO INFORMATION REPORTING ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE This information is necessary to determine whether the sale or exchange should be reported to the seller, and to the Internal Revenue Service on Form 1099-S, Proceeds From Real Estate Transactions. If a residence has more than one owner, each seller must sign the certification. Part 1. Seller Information 1. Name____________________________________________________________________ 2. Address or legal description (including city, state, and zip code) of residence being sold or exchanged ________________________________________________________________ _________________________________________________________________________ 3. Taxpayer Identification Number (TIN)__________________________________________ Part II. Seller Assurances Check "yes" or "no" for assurances (1) through (4). Yes No (1) I owned and used the residence as my principal residence for periods aggregating 2 years or more during the 5-year period ending on the date of the sale or exchange of the residence. (2) I have not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of the residence (not taking into account any sale or exchange before ___________________, __________). (3) No portion of the residence has been used for business or rental purposes by me (or my spouse if I am married) after ________________________, ________. (4) At least one of the following three statements applies: The sale or exchange is of the entire residence for $250,000 or less. OR I am married, the sale or exchange is of the entire residence for $500,000 or less, and the gain oil the sale or exchange of the entire residence is $250,000 or less. OR I am married, the sale or exchange is of the entire residence for $500,000 or less, and (a) I intend to file a joint return for the year of the sale or exchange, (b) my spouse also used the residence as his or her principal residence for periods - 1 - aggregating 2 years or more during the 5-year period ending on the date of the sale or exchange of the residence, and (c) my spouse also has not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of the residence (not taking into account any sale or exchange before ____________________, ________). Part III. Seller Certification Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange. ______________________________________________ _______________________ Signature of Seller Date Print Name: ____________________________________ Forwarding Address: ______________________________________________________________ ______________________________________________________________ - 2 -