Chicago Title NCS Chicago: SYFCREC 2021

1099 REPORTING INFORMATION Please provide the requested information in the spaces provided below. CTIC POLICY NUMBER: ____________________________________________________________ CT&T Co. ESCROW NUMBER: _______________________________________________________ TITLEHOLDING ENTITY: ___________________________________________________________ NAME (as shown on your income tax return):______________________________________________ The name on the “Name” line must be the exact name shown on the income tax return on which the income should be reported. NEW MAILING ADDRESS: __________________________________________________________ __________________________________________________________ TAX IDENTIFICATION NUMBER: ____________________________________________________ GROSS PROCEEDS (purchase price without adjustments): _____________________________________________ PROCEEDS ALLOCATED TO THIS TAX IDENTIFICATION NUMBER: ________ ______________ If more than one tax number is used for reporting proceeds of sale please complete a form for each additional tax number and indicate the respective amount allocated. The total amount for all 1099’s submitted must equal the gross proceeds. IF TRANSFEROR CLAIMS EXEMPTION, CHECK ONE OF THE FOLLOWING: ______ Corporation ______ Governmental Unit ______ Volume Transferor CHECK THE APPROPRIATE CATEGORY OR CATEGORIES: ______ Principal Residence ______ Other Real Estate ______ Check here if the Transferor received or will receive property or services as part of the consideration. CERTIFICATION You are required by law to provide Chicago Title Insurance Company and Chicago Title and Trust Company with your correct taxpayer identification number. If you do not provide Chicago Title Insurance Company and Chicago Title and Trust Company with your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed by law. Under penalties of perjury, I certify that the number shown on this statement is my correct tax identification number. (SIGNATURE) (DATE) 176