Form I-295 Fillable Seller's Affidavit -- Nonresident Seller
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

year of (Affiant's city state and zip code) (Affiant's number street or rural route) (Affiant's SSN or FEIN) (city state and zip code) (involuntary conversions ) If the seller fails to comply with Section 1033 the seller acknowledges an obligation to file an (Name Please Print) (Notary Public) (number street or rural route) (Rev 6/25/10) (Signature) 32781023 32782021 501(a) or is an insurance company exempt from South Carolina taxes on income a certificate of authority to do business in South Carolina or is registered to do business in South Carolina and A gain will be partially recognized Enter the gain amount in item 12 a state to use an individual's social security number as means of identification in administration of any tax SC Regulation 117 201 mandates Advisory Opinion amended South Carolina income tax return for the year of the sale amortization schedule correctly designating the principal and interest portions of the payments If withholding is to be limited and does no business in its state of incorporation or Before me this day of Deemed Resident (must be a business) Pursuant to Code Section 12 8 580(C) and SC Revenue Ruling #09 13 the DEPARTMENT OF REVENUE Employee Relocation The transaction involves the sale of an employee's property which is being sold by an employer or employer or relocation company filing any South Carolina income tax returns (iv) has filed at least one South Carolina income tax return and (v) has Gain Amount The seller affirms pursuant to Code Section 12 8 580(B) that the amount of gain required to be recognized herein could be punished by fine imprisonment or both I 295 I have attached to this affidavit a description of the real property and any tangible personal property being sold as a part of this If the person making the affidavit is not the Seller complete the following: In a simultaneous exchange the entire gain is deferred under Internal Revenue Code Section 1031 information necessary for the Department to fulfill its statutory duties In most instances once this information is collected by the Department it Installment Sale is protected by law from public disclosure In those situations where public disclosure is not prohibited the Family Privacy Protection Act 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 laws (Code Section 12 6 30 et seq ) lien mortgage or credit line advance which was made within one year prior to the closing was not made in contemplation of Like Kind Exchange modified forms and any other information relevant to the withholding including information otherwise confidential in Code My Commission Expires: on this transaction and on which buyer is to make the requisite withholding will not exceed $ Our Internet address is: www sctax org payment If withholding is to be limited to the gain the seller has entered the gain amount in item 12 prevents such information from being used by third parties for commercial solicitation purposes Principal Residence or Involuntary Conversion Nonrecognition of Gain The sale of the property will not be subject to proper identification Your social security number is used for identification purposes relocation company in connection with the employee's transfer For income tax purposes the sale is treated as a sale by the required by SC Revenue Ruling #09 13 have been completed The seller authorizes the qualified intermediary to release Resident The seller is a resident of South Carolina as that term is defined in the South Carolina income tax Retain for your records DO NOT mail to the Department of Revenue S C Code Section 12 8 580 sale The real property is located in the county of and its tax map number(s) is Section 12 54 240 as described in SC Revenue Ruling #09 13 Question 22 Option 2 seller is deemed to be a resident of South Carolina because: SELLER'S AFFIDAVIT NONRESIDENT SELLER WITHHOLDING Social Security Privacy Act Disclosure STATE OF SOUTH CAROLINA SUBSCRIBED AND SWORN to Tax Exempt Organizations The seller is an organization exempt from income taxes under Internal Revenue Code Section taxes because of Internal Revenue Code Section 121 (sale of a principal residence) or Internal Revenue Code Section 1033 that any person required to make a return to the SC Department of Revenue shall provide identifying numbers as prescribed for securing The closing date of this sale is The Family Privacy Protection Act The gain is intended to be deferred under Internal Revenue Code Section 1031 using a qualified intermediary and the steps the sale See Question and Answer 15 in SC Revenue Ruling #09 13 for a discussion of loans made in contemplation of the The seller (i) has been in business in South Carolina during the last two taxable years including the year of sale (ii) The seller agrees to report the sale on a timely filed South Carolina income tax return The seller elects out of the installment sale method for South Carolina purposes and will report the entire withholding in one The seller is a corporation incorporated outside South Carolina has its principal place of business in South Carolina The seller will report this sale on the installment method for South Carolina income tax purposes and has attached an The Seller's address is The Seller's name is The Seller's Social Security Number (SSN) or Federal Employer Identification Number (FEIN) is The undersigned acknowledges his obligation to file a South Carolina income tax return for the year of sale The undersigned is the seller of the property described in the attached description The undersigned on oath being first duly sworn hereby certifies as follows: The undersigned understands that this affidavit may be disclosed to the Department and that any false statement contained This affidavit is being given in connection with a sale of real estate pursuant to SC Revenue Ruling #09 13 This is an affidavit of facts Whether or not this affidavit is sufficient to relieve the buyer of the responsibility to to the gain the seller has entered the gain amount in item 12 Under the Family Privacy Protection Act the collection of personal information from citizens by the Department of Revenue is limited to the will continue substantially the same business in South Carolina after the sale (iii) is not delinquent with respect to withhold is governed by SC Revenue Ruling #09 13 Please read this affidavit carefully in conjunction with this Withholding Amount Equals Entire Net Proceeds If the withholding amount is limited to the entire net proceeds any