Form 13656 - Notice Of Election By Executive And Related Person To Participate In Announcement 2005-19 Settlement Initiative
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4Department of the Treasury — Internal Revenue Service
13656
Form
Notice of Election by Executive and Related Person to
(March 2005)
Participate in Announcement 2005-19 Settlement Initiative
NOTE: The Service can decline to execute a closing agreement with any party that fails to provide all
information requested within this Form 13656.
Section I.
Executive Information
1. Executive name
2. Social security number
(and name of spouse, if joint return)
(SSN)
–
–
(Executive)
–
–
(Spouse)
3. Address
4. Daytime telephone number
(Street, City, State, ZIP code)
(
)
5. FAX number
(
)
6. Executive currently is in Appeals or Examination
7. Executive has executed a Power of Attorney
Yes
No
Yes
No
(Please complete items 8 and 9.)
(Please attach a copy.)
9. Daytime telephone number
8. Name and address
of Appeals Officer or Agent
(Street, City, State, ZIP code)
(
)
I elect to participate in the settlement initiative as described in Announcement 2005-19
and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005. I am
submitting with this election the information and documents requested. Under penalties
Executive
of perjury, I declare that I have examined this Form 13656 and to the best of my
knowledge and belief, it is true, correct and complete.
Attestation
Signature of Executive
Date
Section II.
Related Person Information
1. Name of Related Person to which stock options or restricted stock were transferred
2. Related Person identification
number
(EIN)
3. Address
4. Daytime telephone number
(Street, City, State, ZIP code)
(
)
5. FAX number
(
)
6. Related Person has executed a Power of Attorney
Yes
No
(Please attach a copy.)
13656
Catalog No. 39565K
Sheet 1 of 4
Form
(3-2005)
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