Form Wv/nrae - Application For Certificate Of Full Or Partial Exemption Form - West Virginia State Tax Department Page 2
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4WV/NRAE
Application for Certificate of Full or Partial Exemption
page 2
TrAnSFEror/
your SoCiAl SECuriTy
SEllEr’S nAmE
numbEr/FEin
REAsoN foR full oR pARtiAl ExEmptioN fRom WithholdiNg (attach documentation and calculation)
.
Amount of total payment subject to tax
Reason for exemption (check box if applicable and provide amount of total payment subject to tax)
1. Transfer is to a corporation controlled by a transferor.........................
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2. Transfer is pursuant to a tax-free organization...................................
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3. Transfer is pursuant to an installment sale and the transferor/seller
will receive less than the full purchase price during the taxable year
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4. Transfer is by a tax-exempt entity and transfer involves limited or no
unrelated business taxable income.....................................................
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5. Transfer is by transferor to a partnership, such that no gain or loss is
recognized on the transfer................................................................... 5
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6. Transfer is treated as a transfer by a partnership................................
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7. Transfer is treated as a transfer by a real estate investment trust....... 7
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8. Transfer is a tax-free exchange............................................................ 8
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9. Transfer is pursuant to a condemnation and conversion into similar property............. 9
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10. Transfer is between spouses or incident to divorce........................... 10
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11. Transfer is treated as a transfer by an S corporation......................... 11
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12. Transfer is by transferor to a disregarded entity that is solely owned
by the transferor................................................................................. 12
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13. Transfer is otherwise fully or partially exempt from the recognition
of gain in accordance with the attached explanation......................... 13
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pRoVidE BRiEf ExplANAtioN of youR REAsoN foR REquEstiNg ExEmptioN
cAlculAtioN of tAx to BE WithhEld
1. Enter amount subject to tax........................................................................
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A) 2.5% of total payments or
2. Enter tax rate, whichever applies:
B) 6.5% of estimated capital gains.........
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3. Amount of tax to withheld at closing. Line 1 multiplied by line 2. (This
line must be completed)............................................................................. 3
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Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief it is
true and complete. If prepared by a person other than the transferor/seller, the declaration is based on all information of
which the preparer has any knowledge.
Signature and title (if applicable)
Date
Signature of Spouse (if applicable)
Date
Telephone number
Signature of preparer other than taxpayer
Date
Address and telephone number of preparer
preparer’s SSN or pTiN
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