Withholding agent's name. street address. city. state, and ZIP code

Withholding agent's name. street address. city. state, and ZIP code 1 Date of transfer Statement of Withholding on Dispositions by Foreign Persons of U.S. Real Property Interests 2 Federal income tax withheld OMB No. 1545-0902 Withholding agent's Federal Identification number of foreign person 3 Amount realized 4 Gam recognized by foreign identification number subject to withholding (see ristrucbons) corporation Copy A For Internal Name of person subject to withholding S Description of property transferred Revenue Service Center Foreign address (number. street. and apt. or state no.) 6 Person subject to withhold' g is: An individual O For Privacy Act A corporation O Other (specify( ► and Paperwork Reduction Act City, province or state. postal code, and county (not U.S.) 7 County code Mailing address of person subject to withholding cif different) Notice, see the Instructions for Form 8288. omi 8288-A (Rev. 2-2016) Attach Copies A and B to Form 8288 Department of the Treastry Internal Revenue Service EFTA01222782