Capital Gain Exemption Form

Certification Application for the Capital Gains Exemption

Name and Address
Address of the above-named business' principal office or facility
The above-named business is primarily engaged, or is primarily organized to engage the following field:

Declaration: I, the undersigned officer or other person authorized to act on behalf of the business entity, declare that all information included in this application is, to my knowledge, truthful.

Disclaimer:  Please do not enter sensitive data such as social security numbers on this form.