Non-Foreign Affidavit NON-FOREIGN AFFIDAVIT
STATE OF INDIANA
SS:
COUNTY OF MARION
Wayne L. Beverage(the"Affiant"), in his capacity as the President of WLB Associates, Inc.,
an Oklahoma corporation (the "Transferor"), states that Transferor is transferring to The City of Carmel
Redevelopment Commission (the "Transferee"), the United States real property interest described on
Exhibit A, attached hereto and incorporated herein by reference (the"Real Estate").
Section 1445 of the Internal Revenue Code of 1986, as amended(the"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 term is defined in Section 1445(f)(3) of the Code). To inform Transferee that
Transferee is not required to withhold tax upon disposition by Transferor of the Real Estate, Affiant hereby
certifies the following on behalf of Transferor:
1. Transferor 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 employer identification number is 84-1192690.
3. Transferor's principal office address is 4946 Riley Mews, Carmel, Indiana 46033.
Transferor understands that: (a) Transferee may disclose this Affidavit to the Internal
Revenue Service; and (b) any false statement contained in this Affidavit may be punished by fine,
imprisonment, or both.
Under penalties of perjury, Affiant certifies that: (a) Affiant has examined this Affidavit on
behalf of Transferor; and (b) to the best of the knowledge and belief of Affiant, this Affidavit is true, correct,
and complete. Affiant further certifies that Affiant has authority to sign this Affidavit on behalf of Transferor.
WLB ASSO IATES, INC
i
By: s seh
/ a%ne L. Beverage, President
,,
ACKNOWLEDGMENT
STATE OF INDIANA )
rr11 ) SS:
COUNTY OF}- tr0►1)
Before me, a Notary Public in and for the State of Indiana, personally appeared
Wayne L.Beverage,the President of WLB Associates,Inc.,who acknowledged the execution of the foregoing
Non-Foreign Affidavit on behalf of such entity.
wiii
WITNESS my hand and Notarial Seal thi '6 •C.r..;ir-r>Lysnt400.
VW"
001 PUB 16210._2
q <,....; WILLIAM B.OLSEN By. —
* My Comm.Exp: 6-30-00
Res.of Hamilton Co. Printed Name:
/4'0l AO.' Notary Public
I am a resident of County, Indiana.
My commission expires _
(This document must be retained until the end of the fifth taxable year following the taxable year in which the
transfer takes place.)
-2-1:\Documents\lhouD, Sonny\City of Carmel\Moln lrroor Pedevolopmon[\l.v.r.ft* ProPorcy\NPA.wpd
File No.: 993297
EXHIBIT A.
Lots numbered 1, 14, part of Lots Numbered 2 and 13 and the first alley South of Main Street
which extends between 2nd Avenue S. W. and the railroad (now vacated by an order recorded
April 30, 1976, in Miscellaneous Record 148, page 595, in the Office of the Recorder of
Hamilton County, Indiana) in Ira Mendenhall's Addition to Bethlehem (now Carmel, Indiana)
the plat of which is recorded in Deed Record 23, page 81, in the Office of the Recorder of
Hamilton County, Indiana, more particularly described as follows:
Beginning at the northeast corner of Lot Numbered 1 in Ira Mendenhall's Addition to Bethlehem
(now Carmel, Indiana); thence South on the East line of Lot 1, the Southerly prolongation thereof
and the East line of Lot Numbered 14 a distance of 279 feet to the Southeast corner of said Lot
14; thence Westerly on the South line of said Lot 14 and the South line of Lot 13 a distance of
127.3 feet to a point that is 21.00 feet East of the centerline of the main track of the Monon
Railroad; thence North parallel with said centerline 279 feet to the North line of Lot 2 in said Ira
Mendenhall's Addition; thence Easterly on said North line and the North line of Lot 1 aforesaid a
distance of 131.0 feet to the beginning point.
End of Legal Description