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FIRPTA AFFIDAVIT
STATE OF ______________________ §
§ KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF ___________________ §
Section 1445 of the Internal Revenue Code provides that a transferee of a U.S. real property interest
must withhold tax if the transferor is a foreign person. To inform Orangeburg School District Five
High School for Health Professions (“Transferee”) that withholding of tax is not required upon the
disposition of a U.S. real property interest by Piedmont Companies, Inc. (“Transferor”), Transferor
hereby certifies the following:
1. Transferor is not a foreign corporation, foreign partnership, foreign trust or foreign estate
(as those terms are defined in the Internal Revenue Code and Income Tax Regulations);
2. Transferor’s U.S. employer identification number is: 56-2059075;
3. Transferor is not a “disregarded entity” as defined in IRS Regulation 1.1445-2(b)(iii); and
4. Transferor’s office address is 2671 East Main Street, Lincolnton, NC 28092.
Transferor understands that this certification may be disclosed to the Internal Revenue Service by
the Transferee and that any false statement contained herein could be punished by fine,
imprisonment, or both.
Under penalties of perjury I declare that I have examined this certification and to the best of my
knowledge and belief it is true, correct, and complete, and I further declare that I have authority to
sign this document.
EXECUTED as of (but not necessarily on) this _______ day of _____________, 2018.
TRANSFEROR:
PIEDMONT COMPANIES, INC.
By:
Name:
Title:
SWORN TO AND SUBSCRIBED BEFORE ME this _____ day of _______________, 2018.
[Notarial Seal]
Notary Public, State of
Print Name:
My Commission Expires:

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Firpta affidavit for 5.25.18

  • 1. FIRPTA AFFIDAVIT STATE OF ______________________ § § KNOW ALL MEN BY THESE PRESENTS: COUNTY OF ___________________ § Section 1445 of the Internal Revenue Code provides that a transferee of a U.S. real property interest must withhold tax if the transferor is a foreign person. To inform Orangeburg School District Five High School for Health Professions (“Transferee”) that withholding of tax is not required upon the disposition of a U.S. real property interest by Piedmont Companies, Inc. (“Transferor”), Transferor hereby certifies the following: 1. Transferor is not a foreign corporation, foreign partnership, foreign trust or foreign estate (as those terms are defined in the Internal Revenue Code and Income Tax Regulations); 2. Transferor’s U.S. employer identification number is: 56-2059075; 3. Transferor is not a “disregarded entity” as defined in IRS Regulation 1.1445-2(b)(iii); and 4. Transferor’s office address is 2671 East Main Street, Lincolnton, NC 28092. Transferor understands that this certification may be disclosed to the Internal Revenue Service by the Transferee and that any false statement contained herein could be punished by fine, imprisonment, or both. Under penalties of perjury I declare that I have examined this certification and to the best of my knowledge and belief it is true, correct, and complete, and I further declare that I have authority to sign this document. EXECUTED as of (but not necessarily on) this _______ day of _____________, 2018. TRANSFEROR: PIEDMONT COMPANIES, INC. By: Name: Title: SWORN TO AND SUBSCRIBED BEFORE ME this _____ day of _______________, 2018. [Notarial Seal] Notary Public, State of Print Name: My Commission Expires: