1099 CERTIFICATION

TO:	Melrose Escrow, Inc.

ESCROW NO.:  

We understand that you must provide information pertaining to this escrow to the Internal Revenue Service as required by the Tax Reform Act of 1986, Internal Revenue Code Section 6045(e), 6676, 6722, 6723 and 7203 and issue a Form 1099.

The undersigned Seller(s) hereby provide and authorize the use of the following information for this reporting purpose and understand that if the correct information is not provided, civil or criminal penalties may be imposed by law.

PURCHASE PRICE:		

PROPERTY ADDRESS:	

This is to advise that the TIN Taxpayor's Identification Number (or Social Security Number) for the Seller(s) in this escrow are as follows:

NOTE:  If Seller is an entity (Trust, Partnership, etc.), please provide the entity's TIN/FEIN number, otherwise, if providing a social  security number, the 1099-S must be filed with the IRS as an individual. 

SELLER:

Full Name (Please Print)		Social Security OR Tax Identification Number

			
Full Name (Please Print)		Social Security OR Tax Identification Number

PROPERTY OWNERSHIP STATUS: 	Individual                  Husband and Wife                 Spouses		
	
	Corporation	Partnership                    Trust	 LLC		

Percent of Ownership: 	% (If % of ownership is not 100% another form must be filled out for each Seller).

IS THIS YOUR PRINCIPAL RESIDENCE:	Yes  (  )	No  (  )

EXCHANGE TRANSACTION:	Yes  (  )	No  (  )

ARE YOU A FOREIGN PERSON: 	Yes  (  )	No  (  )
(nonresident alien, foreign partnership,
foreign estate, or foreign trust)

IMPORTANT:  Address for mailing the 1099 at or after the close of escrow will be:

	

Under penalty of perjury, I/We hereby certify the above number(s) and information are true and accurate.

Seller:	 	
	Signature

Seller:	 	
	Signature