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2004-245
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2004-245
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Last modified
4/3/2018 11:24:40 AM
Creation date
9/30/2015 8:17:56 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Miscellaneous
Approved Date
10/19/2004
Control Number
2004-245
Agenda Item Number
None
Entity Name
Dodgertown Venture, LLLP
Subject
Property Exchange portions of former Dodgertown Golf Course
Archived Roll/Disk#
3224
Supplemental fields
SmeadsoftID
4579
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Owner's Affidavit -Page Z <br />B. NON -FOREIGN CERTIFICATE AND REQUEST FOR TAXPAYER IDENTIFICATION NUMBER <br />Section 1445 of the Internal Revenue Code provides that a transferee ("Buyer") of a U.S, real <br />property interest must withhold tax if the transferor ("Self") is a foreign person. For U.S. tax purposes <br />(including section 1445), the owner of a disregarded entity (which has legal title to a U.S. real property <br />interest wider local law) will be the Seller of the property and not the disregarded entity. To inform the <br />Buyer that withholding of tax is not required upon the disposition of a U.S. real property interest by Seller, <br />the undersigned hereby certifies the following on behalf of Seller: <br />1. Seller's Legal Name Is: <br />Dodgertown venture, LLLP <br />2. Seller's Office Address is: <br />3. Seller is not a foreign corporation, foreign partnership, foreign trust, or foreign estate (as <br />those terms are defined in the Internal Revenue Code and Income Tax Regulations). <br />4. Seller is not a disregarded entity as defined in § 1.1445-2(b)(2)(iii), <br />In connection with the sale or exchange of the Property you are required by law to provide <br />Bryant; Miller & Olive, F.A. <br />with your correct taxpayer identification number (TIN). If you do not so provide your 'TIN, you may be <br />subject to civil or criminal penalties imposed by law. <br />5. Seller's Taxpayer Identification Number is: <br />d. For purposes of reporting this transaction to the Internal Revenue Service on Farm 1099-S, <br />the property is Seller's (check one): <br />Principal Residence <br />.. — Other Real Estate <br />This taxpayer identification number is being provided in connection with a real estate <br />transaction <br />The undersigned understand that this Certificate maybe disclosed to the Internal Revenue Service by the <br />Buyer and that any false statement contained herein could be punished by fine, imprisonment or both <br />Under penalties of perjury, 1 declare that I have examined this certification and to the best of my <br />knowledge and belief it is true, correct and complete, and I further declare that I have authority to sign this <br />document as or on behalf of the Seller, and that the number shown on this statement is Seller's correct TIN, <br />Seller states that this instrument is given for the express purpose of inducing <br />Indian River County, a political subidivission of the State of Florida <br />to purchase the Property and to cause Bryant Miller & olive, P.A. <br />as agents for Chicago Title Insurance Company <br />to disburse fiutds and insure title to said property. This Affidavit is made under the full <br />law regarding liability for any misrepresentation herein. <br />0DATED thisa7day of 20/Tone <br />STATE OF Florida <br />COUNTY OF Indian River ' I <br />Swom m and subsmibed before tut d%ia �G <br />John F. Swanson <br />who is penoually (mown to me or wbo lua pmducod <br />Swanson <br />day of Tone, <br />Printed NamIles <br />Notary Public <br />My Commiesian Expire$: <br />of the <br />, 2004 by <br />as identificadou <br />ly, 1000 fNancy H. Mlonali <br />MY COMMISSION # DD179432 EXPIRES <br />•;a,= March 24 2007 <br />ofa RONDEDTHRUTROY FAIN INSURANCE HC <br />TOTAL P.03 <br />
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