Exhibit H - Form Of Firpta Affidavit
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1EXHIBIT H
Form of FIRPTA Affidavit
STATE OF _____________ )
)
ss.:
COUNTY OF _________
)
___________________, being duly sworn, states under penalty of perjury:
(1)
That I am
of
, the seller-transferor
(hereinafter referred to as "Stayton") of property located at
________________________________________, and am familiar with Stayton
and the sale of such property;
(2)
That the United States Tax Identification Number of Stayton is:
; and
(3)
That Stayton is not a "foreign person" as that term is defined in Section
1445(f) of the Internal Revenue Code; and
(4)
That the affidavit is given for the purpose of establishing and documenting
the non-foreign exemption to the withholding of part of the purchase price paid to
Stayton for purchase of the above-referenced property.
_____________________________
Acknowledged and sworn to
before me this
day of
, 20____
_____________________________
Notary Public
010396-0926-08726-Active.11844060
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