Form Ss 5401 PDF Details

In order to help reduce the number of fraudulent tax returns filed each year, the IRS has implemented Form SS 5401. This form is used to verify a taxpayer's identity and eligibility for certain tax credits. Anyone who files a tax return will need to fill out this form, even if they are not claiming any credits. failure to complete this form may result in delays in processing your return or even refusal of your return altogether. So be sure to fill out Form SS 5401 when you file your taxes this year!

QuestionAnswer
Form NameForm Ss 5401
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesSS 5401 no trespassing form tn

Form Preview Example

Division of Publications

Oice of Tennessee Secretary of State Tre Hargett

312 Rosa L. Parks Avenue, 8th Floor Nashville, Tennessee 37243 615-741-2650

Application for the No Trespass Public Notice List

Instructions: Type or print your answers. If an answer does not apply, write “N/A.” Attach additional sheets if you are unable to answer in the space provided. This application must be completed with the following information pursuant to Tenn. Code Ann. § 39-14-405. A nonrefundable registration fee of $25.00, payable to the Department of State, must accompany this application.

1.Name of Business (Full Legal Name): Business Address:

City:

 

 

 

State:

 

 

Zip Code:

 

Phone:

 

 

 

 

Email Address:

 

 

2.If the employer is a corporate entity, please provide the following information of a member, oicer, partner, or other individual with authority to act on behalf of the corporate entity.

Name:

Business Address:

City:

 

 

State:

 

 

Zip Code:

 

Phone:

 

 

 

Email Address:

 

 

3. The address and legal description of the property (provide at least one):

Metes and Bounds Description:

Lot Number:

 

Map and Parcel Number:

Any other description which was accepted for recording by the County Register of Deeds at the

time of the most recent recorded iling for that property and that is contained in the body of the

duly recorded document:

4.Description of employer’s legal basis to assert private property rights over the property (e.g., a leasehold interest, ownership by warranty deed of property, etc.):

SS-5401 (Rev. 10/14)

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5.Required Documents: An applicant must submit a copy of a document or document(s) evidencing the employer’s private property rights. This document may be one of the following:

•A deed that has been duly recorded with the County Register of Deeds of the county in which the property is located and which lists the employer as a grantee of the property.

•A duly recorded contract/purchase agreement which lists the employer as a purchaser.

•A duly recorded easement listing the employer as the person or entity entitled to the easement.

•A power of attorney listing the employer as the grantee, in combination with a duly recorded document evidencing a property ownership interest of the grantor.

•A lease agreement listing the employer as a lessee and the property owner as the lessor, along with a document (as set forth above) evidencing the property owner’s ownership interest in the property.

•A trust instrument evidencing the employer as the trustee or beneiciary of the trust.

•Any other duly recorded document evidencing employer’s legal basis to assert private property rights over the property.

6.The applicant is an employer who intends to provide notice of its private property rights against

criminal trespassers in accordance with Tenn. Code Ann. § 39-14-405(a). Yes No

Signature: This document must be signed by the employer or the individual authorized to act on behalf of the corporate employer.

By signing below, I certify that the statements in this application and all supplemental forms and documents are true and accurate to the best of my knowledge and belief. This signature must be notarized.

 

Signature of Authorized Employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Title (Mr., Mrs., Ms., etc.):

 

 

 

 

 

 

First:

 

 

 

 

 

 

 

 

 

 

 

MI:

 

Last:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position Title:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sworn to and Subscribed before me this

 

 

 

 

day of

 

 

 

 

, 20

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Notary Public)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commission Expires:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Division of Publications is ministerial in function with regard to the iling of the Application and supporting documents and is not responsible for verifying the accuracy or authenticity of the information or documents supplied.

SS-5401(Rev. 10/14)

RDA 2130 Page: 2

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