Date paid

Claim for Deficiency Dividends Deductions by a

Personal Holding Company, Regulated Investment

Company, or Real Estate Investment Trust

Form 976

OMB No. 1545-0045 (Rev. March 2001)

Department of the Treasury

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, street and room or suite no. (If a P.O. box, see instructions.)

City or town, state, and ZIP code

Amount of tax deficiency 1 1

2

3a 3a Amount paid

4 4 Amount unpaid

5 How was the deficiency established?

Tax Court Decision—Attach a copy.

Court Judgment—Attach a copy. If established by a final judgment in a suit against the

United States for refund:

Date the claim for refund was filed

Date the suit was brought

Closing agreement under section 7121.

If a personal holding company, agreement under section 547(c)(3)—Attach a copy of a

properly executed Form 2198.

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)

7 Date the deficiency dividend was distributed.

8 Deficiency dividend was distributed as follows:

Cash 8a

Other property (attach description):

8b(1) (1) Fair market value

Adjusted basis 8b(2) (2)

9a Amount claimed as a deduction for deficiency dividends 9a

For a regulated investment company or real estate investment trust, enter the amount of line

9a designated as capital gain dividends 9b

10 Only personal holding companies must complete line 10.

(c) Amount of deficiency dividend

paid to each shareholder on each

class of stock

(b) Class of stock and number of

shares of each class of stock held at

date of payment of deficiency dividend

(a) Name and address of each shareholder

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is 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

Date SSN or PTIN Check if

self-employed 

Preparer’s Paid signature

Preparer’s

Use Only Firm’s name (or yours,

if self-employed),

address and ZIP Code

EIN

Phone no. ( )

For Paperwork Reduction Act Notice, see back of form. Form 976 (Rev. 3-2001)

b

(1)

(2)

a

b

b

Last day of tax year:









Cat. No. 17061B

a

b

c

d

e

: : . / // // /

(Attach a certified copy of the

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

. / /

. / /

. / /

. / /

. / /
Form 976 (Rev. 3-2001) Page 2

Instructions

Section references are to the Internal Revenue Code.

Recordkeeping 5 hr., 44 min.

Learning about the law or the form 53 min. 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). The form is jointly signed by a delegate of

the Commissioner of Internal Revenue and a qualified officer

of the personal holding company to establish the personal

holding company’s tax liability.

Corporate acquisitions. When the assets of one corporation

are acquired by another corporation in a 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.

If an officer completed 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, such as a clerk, secretary, etc.,

should not sign.

Generally, anyone who is paid to prepare Form 976 must

sign the return and fill in the other blanks in the Paid Deficiency dividends. Deficiency dividends must be Preparer’s Use Only area of the return. distributed no later than 90 days after the deficiency

determination date and prior to filing Form 976. The preparer required to sign the return must complete

the required preparer information and: 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.

● 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 the IRS.

Address. Include the suite, room, or other unit number after

the street address. If the Post Office does not deliver mail to

the street address and the taxpayer has a P.O. box, show the

box number instead of the street address.

Paperwork Reduction Act Notice. We ask for the

information on this form to carry out the Internal Revenue

laws of the United States. You are required to give us the

information. We need it to ensure that you are complying

with these laws and to allow us to figure and collect the right

amount of tax.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is:

If you have comments concerning the accuracy of these

time estimates or suggestions for making this form simpler,

we would be happy to hear from you. You can write to the

Tax Forms Committee, Western Area Distribution Center,

Rancho Cordova, CA 95743-0001. Do not send this form to

this office. Instead, see When and where to file above.

Purpose of form. File Form 976 for a personal holding

company, regulated investment company, or real estate

investment trust that is claiming a deficiency dividend

deduction under section 547 or 860. If the deficiency

dividend deduction is granted, taxpayers will be granted

relief, in whole or in part, from the payment of a tax

deficiency. If the deficiency has already been paid, the

taxpayers 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). A personal

holding company must file Form 976 with the IRS office

where the determination of personal holding company status

was made. A regulated investment company or a real estate

investment trust must file Form 976 with either the IRS office

or the Internal Revenue Service Center where the company

or trust filed its income tax return for the tax year for which

the determination applies.

If the deficiency determination is from an agreement with

the delegate (under section 547(c)(3) or 860(e)(3)) any claim

resulting from the deficiency dividend deduction may be filed

with that IRS office.

Deficiency determination date. The deficiency

determination date is as follows:

● For a decision of the Tax Court, the date the decision

becomes final under section 7481.

● For a 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.

● If an agreement was made by the IRS and the taxpayer

under section 547(c)(3) (Form 2198) (see below) or section

860(e)(3) and the signed copy of the agreement is sent to the

taxpayer by registered mail, the determination date is the

date of the registration. If the agreement is sent by certified

mail, the determination date is the date of the postmark on

the sender’s receipt. But if the dividend is paid before the

registration or postmark date, and on or after the date the

agreement is signed by the delegate of the Commissioner,

the determination date is the date the agreement was

signed.

Claim for credit or refund. If the allowance of the deficiency

dividend deduction results in an overpayment of tax, the

taxpayer must file an amended income tax return in

Signature. The return must be signed and dated by the

president, vice president, treasurer, assistant treasurer, chief

accounting officer, or any other officer (such as tax officer)

authorized to sign. A receiver, trustee, or assignee must sign

and date any return filed on behalf of the company or trust.

Preparing, copying, assembling, and

sending the form to the IRS 1 hr., 2 min.

You are not required to provide the information requested

on a form that is subject to the Paperwork Reduction Act

unless the form displays a valid OMB control number. Books

or records relating to a form or its instructions must be

retained as long as their content may become material in the

administration of any Internal Revenue law. Generally, tax

return and return information are confidential, as required by

section 6103.

addition to Form 976 to obtain a credit or refund of the

overpayment.