Form I-295 - Seller'S Affidavit Nonresident Seller Withholding (Page 2 of 2) in pdf

15.

Principal Residence or Involuntary Conversion - Nonrecognition of Gain. The sale of the property will not be subject to

taxes because of Internal Revenue Code Section 121 (sale of a principal residence) or Internal Revenue Code Section 1033

(involuntary conversions.) If the seller fails to comply with Section 1033, the seller acknowledges an obligation to file an

amended South Carolina income tax return for the year of the sale.

Like Kind Exchange.

16.

In a simultaneous exchange, the entire gain is deferred under Internal Revenue Code Section 1031.

A gain will be partially recognized. Enter the gain amount in item 12.

The gain is intended to be deferred under Internal Revenue Code Section 1031 using a qualified intermediary and the steps

required by SC Revenue Ruling #09-13 have been completed. The seller authorizes the qualified intermediary to release

modified forms and any other information relevant to the withholding, including information otherwise confidential in Code

Section 12-54-240 as described in SC Revenue Ruling #09-13, Question 22, Option 2.

17.

Employee Relocation. The transaction involves the sale of an employee's property which is being sold by an employer or

relocation company in connection with the employee's transfer. For income tax purposes the sale is treated as a sale by the

employer or relocation company.

The undersigned understands that this affidavit may be disclosed to the Department and that any false statement contained

herein could be punished by fine, imprisonment, or both.

(Name - Please Print)

(Signature)

If the person making the affidavit is not the Seller, complete the following:

(Affiant's SSN or FEIN)

(Affiant's number, street or rural route)

(Affiant's city, state and zip code)

SUBSCRIBED AND SWORN to

Before me this

day of

, year of

(Notary Public)

My Commission Expires:

Social Security Privacy Act Disclosure

It is mandatory that you provide your social security number on this tax form if you are an individual taxpayer. 42 U.S.C 405(c)(2)(C)(i) permits

a state to use an individual's social security number as means of identification in administration of any tax. SC Regulation 117-201 mandates

that any person required to make a return to the SC Department of Revenue shall provide identifying numbers, as prescribed, for securing

proper identification. Your social security number is used for identification purposes.

The Family Privacy Protection Act

Under the Family Privacy Protection Act, the collection of personal information from citizens by the Department of Revenue is limited to the

information necessary for the Department to fulfill its statutory duties. In most instances, once this information is collected by the Department, it

is protected by law from public disclosure. In those situations where public disclosure is not prohibited, the Family Privacy Protection Act

prevents such information from being used by third parties for commercial solicitation purposes.

Our Internet address is:

32782021

Form I-295 - Seller'S Affidavit Nonresident Seller Withholding Page 2