976 Claim for Deficiency Dividends Deduction, File
Form or Credit or Refund by a Personal Holding

(Rev. Jan. 1977) in
enanet of he 1 Company or Real Estate Investment Trust Duplicat

jepartment y . ,

Internal Revenue Service (Under Section 547 or Section 859 of the Internal Revenue Code) uplicate
Name of personal holding company or real estate investment trust Employer identification number
Address (Number and street)
City, State and ZIP code
1 Amount of tax deficiency 5 How was the deficiency established?
[J Tax Court Decision—Attach a copy and explain how the decision became final.

2 Taxable year(s) involved {CJ Court Judgment—Attach a copy and explain how the decision became final. If estabished by a final judgment

in a suit against the United States for refund:

3 (a) Amount paid (a) Date the deficiency was paid. 2. . . 1 wk

$ (b) Date the claim for refund was filed... . .. Dm
3 (b) Date pi (c) Date the suit was brought 2 2...
(CJ Closing Agreement Under Section 7121.
4 Amount unpaid [J Ita Personal Holding Company, Agreement Under Section 547(c)(3)—Attach a copy of the agreement.
$ [LJ Ifa Real Estate Investment Trust, Agreement Under Section 859(c)(3)—Attach a copy of the agreement.

6 Determination date (see instruction 4) | 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.

anrtciency 8 (a) Cash 8 (b) Other property (attach description):

distributed (i) Fair market value . . . . . .. . . p> |$
as follows >|  $ (ii) Adjusted basis. . . . . . . . . . hm] $
9 (a) Amount claimed as a deduction 10 If allowance of the deduction for deficiency dividends results in an overpayment of
for deficiency dividends... ss $ tax, enter the amount to be:
(b) If a Real Estate Investment Trust, enter the amount (a) Refunded . . . . . pm» |_S
of line 9(a) designated as capital gain dividends. $ (b) Credited...» | | oS
n (b) Class of stock and number (c) Amount of such dividend
of shares of each class. paid to each shareholder

(a) Name and address of each

‘shareholder held at date of payment on each class of

of deficiency dividend stock

of perjury, | declare that | have examined this claim, including any accompanying schedules and statements, and to the best of my knowl-
is true, correct and complete.

Under pena
edge and belief

Signature of officer ~~" Preparer’s signature (and employer's name, if any) ==s—i=—Cité<C*«éiSN

identifying number (see instructions) ‘Address and ZiP ‘code



Instructions

1. Deficiency Dividends.—Deficiency dividends must
be distributed on, or within 90 days after the determina-
tion date (see instruction 4) 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
taxable year for which the tax liability exists, if it had
been distributed during that year.

2. Who Must File.—This form is to be used in cases
where a personal holding company or real estate invest-
ment trust may be relieved from payment of a tax defi-
ciency, or may be entitled to a credit or refund of part or all
of any such deficiency which has been paid pursuant to sec-
tions 547 or 859 (whichever is applicable). In general, a
real estate investment trust may use this form only with
respect to determinations made after October 4, 1976.

3. How to File.—This claim must be filed, in du-
plicate, within 120 days after the determination date. It
must be filed with the District Director's office where the
determination was made. Attach a certified copy of the
resolution of the board of directors or other authority
authorizing the payment of the deficiency dividend.

4. Determination Date.—The determination date is:

(a) In the case of a decision of the Tax Court, the
date the decision becomes final, as prescribed in
section 7481.

(b) In the case of a judgment, decree or order by a
court, the date the judgment, decree or order be-
comes final.

(c) In the case of a closing agreement made under
section 7121, the date the agreement is approved
by the Commissioner.

(d) In the case of an agreement under section 547
(c)(3) or section 859(c)(3) executed by the Dis-
trict Director (or other authorized official) and

US, GOVERNMENT PRINTING OFFICE: 1977—O-218-231

the taxpayer, if the signed copy of the agree-
ment 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.

5. Claim for Credit or Refund.—If, subsequent to pay-
ment of a tax deficiency, an overpayment results from the
allowance of a deficiency dividend deduction in addition to
this form, a claim must be filed to obtain a credit or refund
for the overpayment.

6. Corporate Acquisitions.—1In the case of the acquisi-
tion of assets of a corporation by another corporation in a
distribution or transfer described in section 381(a), see
sections 381(c)(17) and 381(c)(25) for special rules for
claiming a deficiency dividend deduction.

7. Signature.—The return must be signed and dated
by the president, vice president, treasurer, assistant
treasurer, chief accounting officer, or any other officer au-
thorized to sign. A receiver, trustee, or assignee must sign
and date any return required to be filed on behalf of a
taxpayer.

If the person who prepares the return for pay is not an
employee of a firm, corporation or another individual, then
that person must sign the return as preparer and enter his
or her social security number and address. If the person
who prepares the return for pay is an employee of a firm,
corporation or another individual, then that person must
sign the return and enter the employer's name, identifica-
tion number, and address. If prepared by the taxpayer's
regular, full-time employee, such as a clerk, secretary, or
bookkeeper, the employee does not have to sign.

31-0782030