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r 5. NON-FOREIGN CERTtFICATlON— FlRPTA. Section 1445 of the intema! Revenue Gode provides <br /> that a transfieree (buyer) ofi a U.S. reai property interest musfi withhold tasc ifi the transferor is a fareign <br /> person. For purposes of this paragraph, `Transferee"shall mean"Grantee"and`Transferor"shal! <br /> mean "Granto�". To in#t�rm the Grantee that withhaiding of ta�t is nof required upan the disposition of a <br /> U.S. reai property interest by Grantor, the Grantor hereby cerfiifies the following: <br /> a. �Transferor is the awner af the real property being canveyed; <br /> b. Transferor is not a#oreign person, entity, or disregarded entity{as such terms are ciefined in the <br /> Internai Revenue Code and Income Tau Regulations); and <br /> c. Transferar's U.S.Taxpayer lderttification �I�smber and address set fortl�above are true and correct. <br /> Transferor unders#ands that this certification may be disclosed to the Intemal Rever�ue Service by <br /> Transferee and that any false statement contained herein could be punished by fine, imprisonment or <br /> both. <br /> �nit;al <br /> 6. IE[inois law{15 tLGS 4C?5I10.05 to 405110.05b) requires the Stafe o€ Illinois Comptroller to deduct#rc�m <br /> any State of Illinois warran#s or payments the amount of any outstanding account or claim in favar of <br /> the State of lllinois a►�d any amount necessary to satisfy past due child supporf or de}inquent student <br /> loan and financial aid obligations on any loan guaranteed by the Illinois Student Assistance <br /> Cammission. <br /> 7. This Receip# o# Conveyance Documents and Disbursement 5tatement is the entire and exciusive <br /> agreement between the parties and supersede any written or aral understanding, pramise or <br /> agreement, directly or indirectly rela#ed to the conveyance of parcel and impravements. The parties <br /> agree that any changes ta this Receipt may aniy be made in wri�ing and signed by the parties. <br /> Date: �W�.¢. �F� �-���'I <br /> Grantc�r. City of Decatur, an Illinais municipal corporation <br /> ��'r.S�'- <br /> L���/ l/►�-� � ' <br /> Signature Signatu <br /> U�1� [�1�'�� ��!�� �M nn, �� ���'�� �t l.�-(''�c.. <br /> Print Name(and Title, if applicable) Print Name(and Title, if applica le) <br /> Signature Signature <br /> Print Name (and Title,if applicable) Print Name(and Title,if applicable) <br /> Date: <br /> Grantee: <br /> The People af the State of Ilfinois, Department of Transpartation <br /> for State of Iilinois, Department of Transportation <br /> Page 2 of 2 LA 4112A Template(Rev.0219J16) <br />