HomeMy WebLinkAboutNon-Foreign Affidavit - Brookshire First Mortgage - 12-26-06NON - FOREIGN AFFIDAVIT
STATE OF ILTYoj S )
SS:
COUNTY OF 6-/VF )
Brookshire First Mortgage, LLC ( "Transferor "), states that Transferor is transferring to
City of Carmel Redevelopment Commission ( "Transferee "), a United States real property
interest.
Section 1445 of the Internal Revenue Code of 1986, as amended ( "Code ") provides that a
transferee (buyer) of a United States real property interest must withhold tax if the transferor
(seller) is a "foreign person" as that tern is defined in Section 1445(0(3) of the Code In order
to infonn Transferee that withholding of tax is not required upon the disposition by Transferor of
the real property interest, the undersigned hereby certifies the following:
1. Transferor is not a "foreign person" as that term is defined in Section 1445(0(3)
of the Code and is not a "foreign corporation," "foreign partnership," "foreign
trust" or "foreign estate" (as those terms are defined in the Code and the Income
Tax Regulations promulgated thereunder);
2. Transferor's United States tax identification number is 10- 0000182.
3. Transferor's address is Brookshire First Mortgage, LLC, c/o Old Saybrook Golf
Capital, 37 Water Street, Mystic, CT 06355, Attention Ralph Little.
The undersigned understands that (a) this Affidavit may be disclosed to the Internal
Revenue Service by Transferee, and (b) any false statement contained in this Affidavit may be
punished by fine, imprisonment or both.
Under penalties of perjury, the undersigned swears that this Affidavit is true, correct and
complete.
[The remainder of this page is intentionally left blank.]
270117_2.DOC
BROOKSHIRE FIRST MORTGAGE, LLC
a Delaware limited liability company
By 44:ta
Steven A. Hulce, Designated Manager
270117_ 2