21-0406_ARROYO CAP II-1, LLC_Certificate of Foreign StatusCERTIFICATE OF NON FOREIGN STATUS
(FIRPTA AFFIDAVIT)
Section 1445 of the Internal Revenue Code provides that a transferee (buyer) of a U.S. real property interest
must withhold tax if the transferor (seller) is a foreign person.
To inform Arroyo Cap 11-1 r LLC (the "Transferee")
that withholding of tax is not required upon the disposition of a U.S. real property interest by (the "Transferor"),
the undersigned hereby certifies the following on behalf of the Transferor:
That the Transferor is the owner of the following described property, to wit:
Block: 103 Lot: 31 County:Orange State:CA
oro.:;.. APN 666-131-08
2. The Transferor is not a non-resident alien for purposes of the U.S. income taxation (as such term is defined in
the Internal Revenue Code and Income Tax Regulations).
3. The Transferor's U.S. taxpayer identification number (Social Security Number) is -
4. The Transferor's address is
32400 Paseo Adelanto
San Juan Capistrano CA 92675
5. The Transferor understands that this certification be disclosed to the Internal Revenue Service by the
Transferee and that any false statement contained herein could be punished by fine, imprisonment or both
UNDER PENALTIES OF PERJURY, 1 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
THE TRANSFEROR.
Signed and Swom before me on this ey:
III dayof. Aori\ ,209 rtj ry el
Notary Public
im
23
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of
On i\ (f ��� before me,
(insert name and title of the officer)
personally appeared"'
�t
who proved to me on the basis of satisfac ry evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
CHRISTY A. JAKL
COMM. # 2249471
Z ORANGE COUNTY
QQ NOTARY PUBLIC -CALIFORNIA
MY COMMISSION EXPIRES "
(Seal) JULY 12, 2022