Use this template/form as an Affidavit of Residence or Principal Residence Form in the State of Maryland
Text version of this Form
———————– Page 1———————–
2012 Certification of Exemption from Withholding Upon
MARYLAND Disposition of Maryland Real Estate
FORM Affidavit of Residence or Principal Residence
Based on the certification below, Transferor claims exemption from the tax withholding
requirements of §10-912 of the Tax-General Article, Annotated Code of Maryland. Section
10-912 provides that certain tax payments must be withheld and paid when a deed or other
instrument that effects a change in ownership of real property is presented for recordation. The
requirements of §10-912 do not apply when a transferor provides a certification of Maryland
residence or certification that the transferred property is the transferor’s principal residence.
1. Transferor Information
Name of Transferor
2. Reasons for Exemption
Resident ❑ I, Transferor, am a resident of the State of Maryland.
Status ❑ Transferor is a resident entity as defined in Code of Maryland Regulations (COMAR)
03.04.12.02B(11), I am an agent of Transferor, and I have authority to sign this document
on Transferor’s behalf.
Principal ❑ Although I am no longer a resident of the State of Maryland, the Property is my principal
Residence residence as defined in IRC 121 and is recorded as such with the State Department of
Assessments and Taxation.
Under penalty of perjury, I certify that I have examined this declaration and that, to the best of my
knowledge, it is true, correct, and complete.
3a. Individual Transferors
3b. Entity Transferors
Witness/Attest Name of Entity