om 976

(Rev. December 1986)

Department of the Treasury

Internal Revenue Service (Under Section 547 or 860 of the Internal Revenue Code)

Claim for Deficiency Dividends Deductions by a
Personal Holding Company, Regulated Investment
Company, or Real Estate Investment Trust

OMB No. 1545-0045
Expires 9-30-89

Name of personal holding company, regulated investment company, or real estate investment trust.

Employer identification number

Address (number and street)

City, State, and ZIP code

-

Amount of tax deficiency
2. Tax year(s) involved .
3 (a) Amount paid .
(b) Date paid .
4 Amount unpaid we
5 Howwas the deficiency established?
0 Tax Court Decision—Attach a copy and explain how the decision became final.
] Court Judgment—Attach a copy and explain how the decision became final. If established bya
final judgment in a suit against the United States for refund:
(a) Date the deficiency was paid
(b) Date the claim for refund was filed.
(c) Date the suit was brought

0 Closing agreement under section 7121.
C2 Ifa personal holding company, agreement under section 547(c)(3)—Attach a copy of the agreement.
C0 If a regulated investment company or real estate investment trust, agreement under section

860(e)(3)—Attach a copy of the agreement.

Determination date (see instructions)... 6... ee
7 Date the deficiency dividend was distributed. (Attach a certified copy of the resolution of the board of
directors or other authority authorizing the payment of the deficiency dividend.) . . . . .,.

8 Deficiency dividend was distributed as follows:
(a)Cashh . 2. 2...
(b) Other property (attach description):
(i) Fairmarketvalue. . 2. 2. 2.
(i) Adjustedbasis. 2 2 2...
9 (a) Amount claimed as a deduction for deficiency dividends .

(b) For a regulated investment company or real estate investment trust, enter the amount of line
9(a) designated as capitalgainsdividends . . . . . we el

a

:

SS
S

Th I

10_ Only personal holding companies must complete line 10.

(b) Class of stock and number of
shares of each class held at date of

(a) Name and address of each shareholder
payment of deficiency dividend

(©) Amount of deficiency dividend
Paid to each shareholder on each
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, itis true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here ) Signature of officer Date ) Title
Paid Preparers Date Check if sett Preparer’s social security number
Pre ‘ signature employed > [] : :
reparer’s -
Use Oni Firm's name (or yours, a
y if self-employed) )
and address ZIP code

For Paperwork Reduction Act Notice, see the instructions on the reverse of this form.

Form 976 (Rev. 12-86)


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.

Purpose of Form.—This form is to be used by a personal
holding company, regulated investment company, or real
estate investment trust claiming a deduction for deficiency
dividends under section 547 or section 860 to request relief
from payment of a tax deficiency, or to claim a credit or
refund of part or all of any such deficiency which has been
paid.

When and Where to File.—This claim must be filed within
120 days after the determination date. If filed by a personal
holding company, it shall be filed with the District Director’s
office where the determination was made. If filed by a
regulated investment company or real estate investment
trust, it may be filed with the District Director, or Director of
the Internal Revenue Service Center, with whom the
income tax return was filed for the tax year for which the
determination applies. If the determination is an agreement
with the District Director (or his or her delegate) , the claim
may be filed with the District Director with whom the
agreement was made.

Deficiency Dividends.—Deficiency dividends must be
distributed no later than 90 days after the determination
date (defined below) and prior to filing this claim.

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.

Determination Date.—The determination date is:

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

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

© For a closing agreement made under section 7121, the
date the agreement is approved by the Commissioner; and
@ Foran agreement under section 547(c)(3) or section
860(e)(3) executed by the District Director (or other
authorized official) 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 it is 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.

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.

If 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 and
Order Blanks for Preparers of Federal Income Tax Returns,
for more details.