West Orange Fourth Round HEFSP_adopted 111025_Appendices

GIT/REP-3 (5-12) State of New Jersey SELLER'S RESIDENCY CERTIFICATION/EXEMPTION (C.55, P.L. 2004) {Please Print or Type) SELLER(S) INFORMATION (See Instructions, Page 2) Names(s) THE ARC OF ESSEX COUNTY, INC. Current Resident Address: 123 NAYLON AVENUE Street: City, Town, Post Office State Zip Code LIVINGSTON NJ 07039 PROPERTY INFORMATION (Brief Property Description) Block(s) Lot(s) 2) Qualifier 155, 27 CO177 Street Address: 177 MARION DRIVE City, Town, Post Office -O Zip Code WEST ORANGE NJ 07052 Seller's Percentage of Ownership Consideration Closing Date 100 1.00 06/17/2014 SELLER ASSURANCES (Check the Appropriate Box) (Boxes 2 througi 10 apply to Residents and Non-residents} pursuant to N.J.S.A. 54A:1-1 et seq. and will file a or income from the disposition of this property. resident gross income tax return and pay any applicable taxes pn a 2. [[]The real property being sold or transferred is used exclusivel federal Internal Revenue Code of 1986, 26 U.S.C. s. 121. 3. ol am a mortgagor conveying the mortgaged property to angi in foreclosure or in a transfer in lieu of foreclosure with no 1. Liam a resident taxpayer (individual, estate, or trust) of the State of fa) ipal residence within the meaning of section 121 of the Jersey, the Federal National Mortgage Association al Home Loan Mortgage Corporation, the Government National Mortgage additional consideration. 4. (()Seller, transferor or transferee is an agency or authogi e United States of America, an agency or authority of the State of New Association, or a private mortgage insuranc: Seller is not an individual, estate or trust afd as sugh not required to make an estimated payment pursuant ta N.J.S.A.54A:1-1 ef seq. |The tatal consideration for the property is $7, less and as such, the seller is not required to make an estimated payment pursuant to N.J.S.A. 54A:5-1-1 et se 7. |The gain from the sale will not be plot. (CIRCLE THE APPLICABLI the obfigation to file a New Je! Lo non-like kind property @& for Federal income tax purposes under I.R.C. Section 721, 1031, 1033 or is a cemetery IN}. If such section does not ultimately apply to this transaction, the selier acknowledges tax return for the year of the sale (see instructions). 8. (Transfer by an executor or adfifinistrator of a decedent to a devisee or heir to effect distribution of the decedent's estate in accordance with

eturn for the year of the sale (see instructions). 8. (Transfer by an executor or adfifinistrator of a decedent to a devisee or heir to effect distribution of the decedent's estate in accordance with the provisions of the decedent's will or the intestate laws of this state. 9. [TThe property being sold is subject to a short sale instituted by the mortgagee, whereby the seller has agreed not to receive any proceeds from the sale and the mortgagee will receive all proceeds paying off an agreed amount of the mortgage. 10. Othe deed being recorded is a deed dated prior to the effective date of PL. 2004, c. 55 (August 1, 2004), and was previously unrecorded. SELLER(S) DECLARATION The undersigned understands that this declaration and its contents may be disclosed or provided to the New Jersey Division of Taxation and that any false statement contained herein could be punished by fine, imprisonment, or both. | furthermore declare that | have examined this declaration and, to the best of my knowledge and belief, it is true, correct and complete. By checking this box 1 | certify that the Power of Attorney to represent the selller(s) has been previously recorded or is being recorded simultaneously with the deed to which this form is atta 06/17/2014 Date gignature * {Seller) Please indicate if Power of Attorney or Antorney in Fact Date Signature (Seller) Please indicate if Power of Attorney or Attorney in Fact