com 916 Claim for Deficiency Dividends Deductions by a
(hen Juy 1989) Personal Holding Company, Regulated Investment — | °”?"**c0%

Company, or Real Estate Investment Trust Expires 7-31-92
Department of the Treasury i
Internal Revenue Service (Under Section 547 or 860 of the Internal Revenue Code)
Name of personal holding company, regulated investment company, or real estate investment trust Employer identification number

Number and street (or P.O. box number if mail 1s not delivered to street address)

City or town, state, and ZIP code

1 Amount oftaxdeficiency 2... ee ee ee ee Pd
2 Tax year(s) involved _... . . a Mh
3(a)Amountpaid. 2. ee PA
(b) Date paid Ms
4 Amount unpaid ery Se ee ee
5 How was the deficiency established? Y Yf
0 Tax Court Decision—Attach a copy.
O Court Judgment—Attach a copy. If established by a final judgment in a suit against the United
States for refund:
(a) Date the claim for refund was filed
(b) Date the suit was brought ___.
O Closing agreement under section 7121.
LC If a personal holding company, agreement under section 547(c)(3)—Attach a copy of a properly
executed Form 2198.
CO If a regulated investment company or real estate investment trust, agreement under section
860(e)(3)—Attach a copy of the agreement.
6 Deficiency determination date (see instructions) __o oo...
7 Date the deficiency dividend was distributed _... . 19, . (Attach a certified copy of the

resolution of the board of directors or other authority authorizing the payment of the deficiency dividend.)

119

8 Deficiency dividend was distributed as follows: Uh
(a)Cash 2... we we ee sae .
(b) Other property (attach description): M
() Fairmarketvalue. 2 0 6 ee  BOOO
(i) Adjustedbasis. 6 ee ee (BONED
9 (a) Amount claimed as a deduction fordeficiencydividends. . . 2. 1 1 ee ee ee 9(a)
(b) For a regulated investment company or real estate investment trust, enter the amount of line
9(a) designated as capitalgainsdividends . . . . . . . . . . . ss +s - + | 9b)
10 Only personal holding companies must complete line 10.
(b) Class of stock and number of (©) Amount of deficiency dividend
(a) Name and address of each shareholder shares of each class held at date of paid to each shareholder on each
payment of deficiency dividend class of stock

Under penalties of perjury, | declare that | have examined this claim, including accompanying schedules and statements, and to the best of my knowledge and
Please belief, it 1s true, correct, and complete. Deciaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here ) Signature of officer Date » Title
i, Preparer's Date Check if s Preparer's social security number
Pa ers signature » empioyed > (J :
Firm's name (or yours, ElLNo. &
Use Only if self-employed) )
and address ZIP code

For Paperwork Reduction Act Notice, see the instructions on the reverse of this form. Form 976 (Rev. 7-89)


Form 976 (Rev. 7-89)

Page 2

Instructions
(Section references are to the Internal Revenue Code.)

Paperwork Reduction Act Notice.—We ask for this
information to carry out the Internal Revenue laws of the
United States. We need it to ensure that taxpayers are
complying with these laws and to allow us to figure and
collect the right amount of tax. You are required to give us
this information.

The time needed to complete and file this form will vary
depending on individual circumstances. The estimated
average time is:

Recordkeeping 5 hrs., 44 min.
Learning about the law or

the form . . - 47 min.
Preparing, copying,

assembling, and sending

the form to IRS . 55 min.

If you have comments concerning the accuracy of these
time estimates or suggestions for making the form more
simple, we would be happy to hear from you. You can write
to the Internal Revenue Service, Washington, DC 20224,
Attention: IRS Reports Clearance Officer, T:FP, or the
Office of Management and Budget, Paperwork Reduction
Project (1545-0045), Washington, DC 20503.

Purpose of Form.—A personal holding company,
regulated investment company, and real estate investment
trust files Form 976 to claim a deficiency dividend
deduction under section 547 or 860. If the deficiency
dividend deduction is granted, these entities will be granted
relief, in whole or in part, from the payment of a tax
deficiency. If a deficiency has been paid, these entities
must file an amended return to claim a credit or refund.
When and Where To File.—File Form 976 within 120 days
after the deficiency determination date (defined below).
Personal holding companies must file Form 976 with the
District Director's office where the determination of
personal holding company status was made. Regulated
investment companies or real estate investment trusts may
file Form 976 with either the District Director or the
Director of the Internal Revenue Service Center with whom
the company or trust filed its income tax return for the year
to which the determination applies.

lf the deficiency determination is from an agreement
with the District Director or delegate (under section
547(c)(3) or 860(e)(3)), any claim resulting from the
deficiency dividends deductions may be filed with that
District Director.

Deficiency Dividends.—Deficiency dividends must be
distributed no later than 90 days after the deficiency
determination date and prior to filing Form 976.

The deficiency dividend must be of such a nature as
would have permitted its inclusion in the computation of
the deduction for dividends paid under section 561 for the
tax year for which the tax liability exists, if it had been
distributed during that year.

Deficiency Determination Date.—The deficiency
determination date is:

@ Fora decision of the Tax Court, the date the decision
becomes final, as prescribed in section 7481;

e Fora judgment, decree, or order by a court, the date the
judgment, decree, or order becomes final;

e Foraclosing agreement made under section 7121, the
date the agreement is approved by the Commissioner; and
e For an agreement under section 547(c)(3) (Form 2198)
or section 860(e)(3) executed by the District Director (or
delegate) and the taxpayer, if the signed copy of the
agreement is sent to the taxpayer by registered mail, the
determination date is the date of registration. If itis sent by
certified mail, the determination date is the date of the
postmark on the sender’s receipt. However, if a dividend is
paid by the taxpayer before such registration or postmark
date, but on or after the date the agreement is signed by
the District Director, the determination date shall be the
date of such signing.

Form 2198.—Form 2198, Determination of Liability For
Personal Holding Company Tax-Section 547(c)(3) of the
Internal Revenue Code, is used as the agreement required
by section 547(c)(3) of the Internal Revenue Code. The
form is jointly signed by a delegate of the Commissioner of
Internal Revenue Service and a qualified officer of the
personal holding company to establish the personal holding
company’s tax liability.

Claim for Credit or Refund.—If, after payment of a tax
deficiency, an overpayment results from the allowance of a
deficiency dividend deduction, a claim, in addition to this
form, must be filed on an appropriate amended income tax
return to obtain a credit or refund for the overpayment.
Corporate Acquisitions.—When the assets of one
corporation are acquired by another corporation ina
distribution or transfer described in section 381(a), see
sections 381(c)(17) and 381(c)(23) for special rules for
claiming a deficiency dividend deduction.
Signature.—The return must be signed and dated by the
president, vice president, treasurer, assistant treasurer,
chief accounting officer, or any other corporate officer
(such as tax officer) authorized to sign. A receiver, trustee,
or assignee must sign and date any return required to be
filed on behalf of a corporation.

\f a corporate officer filled in Form 976, the Paid
Preparer’s space under “‘Signature of officer’ should
remain blank. If someone prepares Form 976 and does not
charge the corporation, that person should not sign the
return. Certain others who prepare Form 976 should not
sign. For example, a regular, full time employee of the
corporation, such as a clerk, secretary, etc., does not have
to sign.

Generally, anyone who is paid to prepare Form 976 must
sign the return and fill in the other blanks in the Paid
Preparer's Use Only area of the return.

The preparer required to sign the return MUST complete
the required preparer information and:

@ Sign it, by hand, in the space provided for the preparer’s
signature (signature stamps or labels are not acceptable);
and

@ Give a copy of Form 976 to the taxpayer in addition to
the copy filed with IRS.

Tax return preparers should be familiar with their
responsibilities. See Publication 1045, Information for Tax
Practitioners, for more details.