Non-Foreign Affidavit - Marshall E. Andich NON-FOREIGN AFFIDAVIT
Marshall E. Andich
STATE OF INDIANA )
) SS:
COUNTY OF )
Marshall E. Andich (the "Transferor"), states that he is transferring to The City of Carmel
Redevelopment Commission (the "Transferee"), certain United States real property located in Hamilton
County, Indiana (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
withholding of tax is not required upon the disposition by Transferor of the Real Estate, Transferor hereby
certifies the following:
1. Transferor is neither:(a)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); nor(b)a nonresident alien for purposes of United States Income
Taxation;
2. Transferor's taxpayer identification number is ; and
3. Transferor's home address is -45 u300d0-C "PYI\CQ l C , . t/In t. IN 4X032
1
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,Transferor certifies that:(a)he has examined this Affidavit;
and (b) it is true, correct, and complete. _
By:
arshall E. Andich
ACKNOWLEDGMENT
Before me, a Notary Public in and for the State of Indiana, personally appeared
Marshall E. Andich, who, having been first duly sworn, acknowledged the execution of the foregoing
Non-Foreign Affidavit.
WITNESS my hand and Notarial Seal this d:y i f ; it. . , 2004.
�`�`• <� WILLIAM B.OLSEN By'
,7.t.,f s E�1d. * My Comm.Exp: 06-30-08 I' Lr.. JI-
Res.of Hamilton Co.
on/D/0: Printed Name:
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 ye..-JD..., - c the �'
transfer takes place.) �. !�
rt.,-
tCEIWD \ �\
y ; 2004
COGS
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