Form 8288-A - Statement Of Withholding On Dispositions By Foreign Persons Of U.s. Real Property Interests Form Page 2

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Withholding agent’s name, street address, city, state, and ZIP code
1 Date of transfer
Statement of Withholding on
Dispositions by Foreign Persons
of U.S. Real Property Interests
2 Federal income tax withheld
OMB No. 1545-0902
Copy B
Withholding agent’s Federal
Identification number of foreign person
3 Amount realized
4 Gain recognized by foreign
identification number
subject to withholding (see instructions)
corporation
Send to
Internal
Revenue
Name of person subject to withholding
5 Description of property transferred
Service Center
(For Use by
Person
Foreign address (number, street, and apt. or suite no.)
6 Person subject to withholding is:
An individual
Subject to
Withholding)
A corporation
Other (specify)
City, province or state, postal code, and country (not U.S.)
7 Country
Mailing address of person subject to withholding (if different)
This information is
code
being furnished to
the Internal
Revenue Service.
8288-A
Form
(Rev. 6-2011)
Department of the Treasury - Internal Revenue Service

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