1099-S CERTIFICATION EXEMPTION FORM
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 'yes'
response to assurances (1) through (4) in Part II, 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
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 "yes" or "no" for assurances (1) through (4).
___ ___ (1) I owned and used the residence as my 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 during the 5-year period
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 exchange of the residence
(not taking into account any sale or exchange before May 7, 1997).
___ ___ (3) No portion of the residence has been used for business or rental
purposes by me (or any spouse if I am married) after May 6 1997.
___ ___ (4) At least one of the following three statements applies:
The sale or exchange is of the entire residence for $250,000 or less.