3528-A Form - Application For New Home Credit

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CALIFORNIA FORM

TAXABLE YEAR

3528-A

Application for New Home Credit

2009

Part I Seller’s Certification

PRINT CLEARLY

(Important: Use this form only with the sale of a home that has never been occupied)

Seller’s Name

FEIN or CA Corp no.

Secretary of State (SOS) file number

SSN or ITIN

Address (including suite, room, PO Box, or PMB no.)

City

State ZIP Code

Address of Property Sold

Parcel Number

County

City

State ZIP Code

Perjury Statement

Under penalties of perjury, I hereby certify that the property is a single family residence that has never been previously occupied. I certify that the

information provided above is, to the best of my knowledge, true and correct.

Seller’s Signature: ___________________________________________________________________________ Date: _________________________

Seller’s Contact Name: _____________________________________________________ Telephone Number (________) ________ - ______________

Part II Escrow Information

1 Escrow Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 1 ____________________

2 Date Escrow Closed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 2 ____________________

YYYY

Escrow Company Name _______________________________________________________________________

Contact Person ______________________________________________________________________________

Contact Person Telephone Number (_____) _____-______

3 Total Purchase Price . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I 3

4 Will all the buyers be living in the home as their principal residence? Check applicable box. If Yes, go to line 5.

If No, skip line 5 and see line 6 instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

5. Enter 5% (.05) of the Total Purchase Price (line 3) or $10,000, whichever is less. This is the total credit amount. . . . .I 5

Do not complete Line 6 or Line 7 if you checked Yes to Line 4.

6 Enter the Qualified Purchase Price. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I 6

7 Enter 5% (.05) of the Qualified Purchase Price (line 6) or $10,000, whichever is less. This is the total credit amount . . .I 7

FAX completed Form (Side 1 and Side 2) to: 916.845.9754

FTB 3528-A

2009 (REV.2 03-09) Side 1

8161093

For Privacy Notice, get form FTB 1131.