Form 8288-A - Statement Of Withholding On Dispositions By Foreign Persons Of U.s. Real Property Interests Form Page 3

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1 Date of transfer
Withholding agent’s name, street address, city, state, and ZIP code
Statement of Withholding on
Dispositions by Foreign Persons
of U.S. Real Property Interests
2 Federal income tax withheld
OMB No. 1545-0902
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
Copy C
For
Withholding
Name of person subject to withholding
5 Description of property transferred
Agent
For Privacy Act
Foreign address (number, street, and apt. or suite no.)
6 Person subject to withholding is:
An individual
and Paperwork
A corporation
Other (specify)
▶
Reduction Act
City, province or state, postal code, and country (not U.S.)
7 Country
Mailing address of person subject to withholding (if different)
Notice, see the
code
Instructions for
Form 8288.
8288-A
Keep for your records
Form
(Rev. 6-2011)
Department of the Treasury - Internal Revenue Service

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