Certification Sample

Internal Revenue Bulletin - January 22, 2007

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APPENDIX
CERTIFICATION FOR NO INFORMATION REPORTING ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE
This form may be completed by the seller of a principal residence. This information is necessary to determine whether the sale or exchange
should be reported to the seller, and to the Internal Revenue Service on Form 1099-S, Proceeds From Real Estate Transactions. If the seller
properly completes Parts I and III, and makes a “true” response to assurances (1) through (6) in Part II (or a “not applicable” response to
assurance (6)), no information reporting to the seller or to the Service will be required for that seller. The term “seller” includes each owner of
the residence that is sold or exchanged. Thus, if a residence has more than one owner, a real estate reporting person must either obtain a
certification from each owner (whether married or not) or file an information return and furnish a payee statement for any owner that does not
make the certification.
Part I. Seller Information
1. Name
2. Address or legal description (including city, state, and ZIP code) of residence being sold or exchanged

3. Taxpayer Identification Number (TIN)
Part II. Seller Assurances
Check “true” or “false” for assurances (1) through (5), and “true”, “false”, or “not applicable” for assurance (6).
True False
(1) I owned and used the residence as my principal residence for periods aggregating 2 years or more during the 5-year period
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ending on the date of the sale or exchange of the residence.
(2) I have not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or
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exchange of the residence.
(3) I (or my spouse or former spouse, if I was married at any time during the period beginning after May 6, 1997, and ending
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today) have not used any portion of the residence for business or rental purposes after May 6, 1997.
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(4) At least one of the following three statements applies:
The sale or exchange is of the entire residence for $250,000 or less.
OR
I am married, the sale or exchange is of the entire residence for $500,000 or less, and the gain on the sale or exchange of the
entire residence is $250,000 or less.
OR
I am married, the sale or exchange is of the entire residence for $500,000 or less, and (a) I intend to file a joint return for the
year of the sale or exchange, (b) my spouse also used the residence as his or her principal residence for periods aggregating 2
years or more during the 5-year period ending on the date of the sale or exchange of the residence, and (c) my spouse also
has not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of
the principal residence.
(5) During the 5-year period ending on the date of the sale or exchange of the residence, I did not acquire the residence in an
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exchange to which section 1031 of the Internal Revenue Code applied.
True False N/A
(6) If my basis in the residence is determined by reference to the basis in the hands of a person who acquired the residence in
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[ ] an exchange to which section 1031 of the Internal Revenue Code applied, the exchange to which section 1031 applied
occurred more than 5 years prior to the date I sold or exchanged the residence.
Part III. Seller Certification
Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange.
Signature of Seller Date

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12/8/2016

Internal Revenue Bulletin - January 22, 2007

https://www.irs.gov/irb/2007-04_IRB/apa.html

Page 2 of 2

12/8/2016