This affidavit certifies that a non-resident seller of Mississippi real estate swears under penalty of perjury to key sale details, gain computation, and 5% income tax withholding amount for the Mississippi Department of Revenue. Buyers use it to determine withholding: the lesser of 5% of gain or net proceeds payable to seller. Complete both pages with Schedule A (gain calculation) and Schedule B (net proceeds), notarize the seller’s signature, and mail original to MS Department of Revenue, P.O. Box 23050, Jackson, MS 39225-3050. Seller commits to filing all due MS income tax returns. Only deduct mortgages/liens over one year old or with seller affidavit confirming not in contemplation of sale; recent advances require separate proof.
How to Complete the Form
Complete page 1 and both schedules on page 2. Sign before notary. Mail original with all details to specified address. Buyer retains copy for withholding records and remits tax.
Page 1: Seller Affidavit
Seller’s Name
Enter full legal name of non-resident seller.
Seller’s Name and Address
Enter seller’s complete address: street, city, state, ZIP.
Description, location and tax map parcel number of property sold
Describe property fully, including physical location and parcel ID.
Buyer’s Name and Address
Enter buyer’s full name and complete address: street, city, state, ZIP.
Closing date
Enter MM/DD/YYYY of closing.
The total sales price is
Enter full amount from Schedule A, line 1.
The gain to be reported on the seller’s MS Income Tax Return (From Page 2, Schedule A, Line 5)
Copy gain from Schedule A, line 5.
Income tax at 5% of the gain (Line 5 multiply by 5%)
Multiply line 5 by 0.05.
The net proceeds payable to the seller (From Page 2, Schedule B, Line 5)
Copy net proceeds from Schedule B, line 5.
Income tax amount required to be withheld (Enter the smaller of line 6 or line 7)
Enter lesser of line 6 or line 7.
The seller will file all state Income Tax Returns due
State commitment to file.
[Seller prefaces affidavit text]
Non-resident seller, duly swears under penalty of perjury the following facts.
Social Security Number
Enter seller’s SSN.
Seller’s Signature
Sign personally.
Social Security Number or ID Number of Spouse
Enter spouse’s SSN/ID if applicable.
Signature of Spouse
Spouse signs if joint.
Witness my signature, this the Day of , 20
Enter date signed.
Notary Section
State of
Enter state of notarization.
County of
Enter county.
This day personally appeared before me…
Notary verifies seller’s identity and acknowledgment.
Given under my hand and seal, this the Day of , 20
Notary date.
My Commission Expires
Notary expiration date.
Notary Public
Notary signs and seals.
Page 2: Schedule A – Computation of Gain
Line 1: Total sales price
Enter gross sales price.
Line 2: Less selling expenses
Itemized: Attorney fees; Real estate commission; Termite, heating & air letter fees; Other – list specifics.
Line 3: Net sales price (Line 1 minus Line 2)
Subtract total line 2 from line 1.
Line 4: Less tax basis
Enter seller’s adjusted basis in property.
Line 5: Gain for tax purposes (Line 3 minus Line 4, enter here and on Page 1, Line 5)
Subtract line 4 from line 3. Carry to page 1.
Page 2: Schedule B – Computation of Net Proceeds
Line 1: Total sales price
Copy from Schedule A, line 1.
Line 2: Less selling expenses
Copy itemized totals from Schedule A, line 2.
Line 3: Net sales price (Line 1 minus Line 2)
Copy from Schedule A, line 3.
Line 4: Less mortgages, liens or advances on credit lines not made in contemplation of the sale
Deduct only eligible items: property-specific, over 1 year old, or with seller affidavit.
Line 5: Net proceeds payable to the seller (Line 3 minus Line 4, enter here and on Page 1, Line 7)
Subtract line 4 from line 3. Carry to page 1.