Form 13656 - Notice Of Election By Executive And Related Person To Participate In Announcement 2005-19 Settlement Initiative Page 2
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2
3
4Section II. Related Person Information —
continued
Related Person Attestation
All partners/members of the Related Person 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.
Under penalties 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.
Name
Signature
Date
(Please print.)
1 .
Name
Signature
Date
(Please print.)
2.
Name
Signature
Date
(Please print.)
3.
Name
Signature
Date
(Please print.)
4.
Name
Signature
Date
(Please print.)
5.
Name
Signature
Date
(Please print.)
6.
Name
Signature
Date
(Please print.)
7.
Name
Signature
Date
(Please print.)
8.
Section III.
Corporation Information
1. Name of corporation that issued the stock options or restricted stock
2. Corporation identification
number
(EIN)
3. Address
4. Daytime telephone number
(Street, City, State, ZIP code)
(
)
5. FAX number
(
)
6. Is the corporation electing to participate in this settlement initiative?
Yes
No
Unknown
7. Name of corporation that received the services from the Executive
8. Corporation identification
(if different from the
corporation named in Section III, Item 1)
number
(EIN)
9. Address
10. Daytime telephone number
(Street, City, State, ZIP code)
(
)
11. FAX number
(
)
13656
Sheet 2 of 4
Department of the Treasury – Internal Revenue Service
Form
(3-2005)
Catalog No. 39565K
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