Form 4797n - Special Capital Gains/extraordinary Dividend Election And Computation - 2007

Download a blank fillable Form 4797n - Special Capital Gains/extraordinary Dividend Election And Computation - 2007 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 4797n - Special Capital Gains/extraordinary Dividend Election And Computation - 2007 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

SPECIAL CAPITAL GAINS/EXTRAORDINARY DIVIDEND

FORM 4797N

ELECTION AND COMPUTATION

2007

• Attach a copy of Federal Schedule D or other appropriate federal documentation

• Attach this page to Form 1040N or 1041N

Your Name as Shown on Form 1040N

Social Security Number

READ THIS BEFORE YOU BEGIN:

Complete PART I if an election has not been previously made and you are qualiﬁed to make the special capital gains or extraordinary

dividend election for the qualiﬁed stock. Those qualiﬁed to make the election primarily are employees, but may include a surviving

spouse or oldest issue (e.g., child, grandchild). If you are not the employee, FIRST COMPLETE PART III on the reverse side of

this form to determine if you are qualiﬁed to make the initial election. PART II computes the income exclusion and is completed

only after a proper election has been made. If ﬁling to claim both a capital gains exclusion and to exclude an extraordinary dividend

paid, complete two separate PART II INCOME EXCLUSION calculations. Combine the allowable exclusion amounts from line 14 of

each calculation and enter on appropriate line of Form 1040N or Form 1041N. Attach a worksheet showing this.

PART I ELECTION

• Complete this part to make the Special Capital Gains/Extraordinary Dividend Election

Name of Employee Who Originally Acquired the Stock

Employee’s Social Security Number

1 Has employee (or another qualiﬁed individual on behalf of the employee) made a

2 Complete the following statement by checking the applicable box:

previous special capital gains or extraordinary dividend election?

I am the:

Employee

Surviving Spouse

Oldest Issue

YES

If you checked Employee, you qualify to make the election.

If Yes, do not complete the remainder of Part I. Instead, attach a copy of the

If you checked Surviving Spouse or Oldest Issue, you must complete

previous election (Form 4797N), and enter the tax year election was made _______.

Part III to see if you qualify to make the election (see instructions).

If No, complete Part I to make the election.

3 Was the stock acquired by the employee because of employment by the issuing

4 Name of Corporation Issuing Stock for Which This Election is Made:

corporation or while employed by the issuing corporation?

YES

6 Has the corporation which issued the stock conducted business in Nebraska for three

5 Description of the Stock

years immediately preceding the time of the ﬁrst sale or exchange?

YES

7 Was the corporation a publicly traded corporation?

8 If you answered No to question 7, how many shareholders did the corporation have at

the time of the ﬁrst sale or exchange of stock or declaration of extraordinary dividend?

YES

If No, answer questions 8 and 9.

9 If you answered No to question 7, did a shareholder or group of related shareholders hold more than 90% of the stock at the time of the ﬁrst sale or exchange of stock or

declaration of extraordinary dividend?

YES

I hereby elect to receive the special capital gains/extraordinary dividend treatment provided under Section 77-2715.09, R.R.S. 2007, and declare

under penalties of perjury that to the best of my knowledge and belief, the capital stock described above qualiﬁes for the special capital gains/extraordinary

dividend election.

sign

here

Signature of Employee, Surviving Spouse, or Oldest Issue Making this Election

Date

RESET

SAVE

PART I — INSTRUCTIONS

This irrevocable one-time election may be made by any full-

surviving issue (e.g., child, grandchild) may make the election

year resident individual who acquired the capital stock of a

if the election could have been made by the employee.