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Ation of Total Payment and Tax to be Withheld (See Instructions) 2. Date of transfer 3. Check box if the transferor/ seller is reporting gain under the installment method 4. Transferor/Seller s identification no. (SSN or FEIN) (Enter only one number) 5. Spouse s SSN 6. Transferor/Seller s name (Enter only one name, unless husband and wife filing a joint return. If more than one transferor/seller, use separate forms for each) Street address City, state and ZIP code a. b. c. d. e..

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