FIRPTA Affidavit by Transferor to Reliability Incorporated Regarding The Maslow Media Group, Inc.
This affidavit is made by the transferor of interests in The Maslow Media Group, Inc. to Reliability Incorporated. The transferor certifies that they are not a foreign person under U.S. tax law, providing their taxpayer identification number and address. This certification informs the transferee that no tax withholding is required under Section 1445 of the Internal Revenue Code. The transferor acknowledges that false statements may result in penalties and that the certification may be disclosed to the IRS.
Exhibit 10.4
FIRPTA AFFIDAVIT
Section 1445 of the Internal Revenue Code of 1986, as amended (the “Code”) provides that a transferee of a U.S. real property interest must withhold tax if the transferor is a foreign person. To inform Reliability Incorporated, a Texas corporation (the “Transferee”) that withholding of tax is not required upon the disposition of interests in The Maslow Media Group, Inc., a Virginia corporation (the “Company”) by the undersigned transferor (the “Transferor”), the undersigned hereby certifies the following on behalf of Transferor:
| 1. | Transferor is not a “foreign person” (as defined in the Code and Treasury Regulations). |
2. Transferor’s U.S. taxpayer identification number is ________________________.
| 3. | Transferor’s address is :________________________ |
4. Transferor understands that this certification may be disclosed to the Internal Revenue Service by 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 on behalf of Transferor.
Dated: _______, 2019
TRANSFEROR NAME: _____________________________________
By: ______________________________
Name: ______________________________
Title: ______________________________
(if applicable)
