Form 13656 - Notice Of Election By Executive And Related Person To Participate In Announcement 2005-19 Settlement Initiative Page 3
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2
3
4Information and Documentation Required to Process Election by
Section IV.
Executive and Related Person
Answer the following questions and provide the listed documentation. If you need additional space for your answers,
please attach additional sheets and identify the continued answers by item number. “
” means
Provide documentation
“Attach copies of documents that verify your responses.”
1.
What did the Related Person transfer to the Executive in exchange for the stock options or restricted stock the Executive
transferred to the Related Person? On what date
did the transfer or sale occur? Provide documentation
(s)
(including copies of any
.
promissory notes and appraisal reports)
2.
On what date
did the Related Person exercise stock options it received from the Executive? Does the Related Person still hold
(s)
options it has not exercised?
Yes
No
(Or, on what date did the restricted stock vest?)
What was the fair market value of the stock on the exercise date or the date of vesting? Provide documentation.
3.
Has the Related Person paid any amounts
to
4.
Did the Related Person or the Executive pay any transaction
(including interest)
the Executive?
costs
?
(including promoter, accounting, appraisal, and legal fees)
Yes
Yes
(Provide documentation of all payments.)
(Provide documentation of all payments.)
No
No
5.
Has the Related Person sold all the stock it acquired through this transaction
?
(including stock acquired by exercising options)
Yes
No
(See below.)
Note:
For any stock sold, provide a schedule listing the number of shares sold, the date of sale, the sales price, and the claimed basis
at the date of sale. Provide documentation.
6.
Provide copies of all promotional packages, legal opinions, or engagement letters obtained by the Executive or the Related Person
pertaining to this transaction.
(or any person acting on their behalf)
7.
Provide the name, address, and telephone number of the entity and person
that sold or promoted the sale of the transaction
(s)
described in Announcement 2005-19 to the Executive or the Related Person.
8.
Provide a computation of any tax and penalty due from the Executive under the terms of Announcement 2005-19.
9.
Provide a computation of the Related Person's basis in stock still held pursuant to Announcement 2005-19.
13656
Sheet 3 of 4
Department of the Treasury – Internal Revenue Service
Form
(3-2005)
Catalog No. 39565K
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