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Notice Concerning Fiduciary Relationship
Form
OMB No. 1545-0013
(Rev. November 2017)
Go to for instructions and the latest information.
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Department of the Treasury
(Internal Revenue Code sections 6036 and 6903)
Internal Revenue Service
Part I
Identification
Name of person for whom you are acting (as shown on the tax return)
Identifying number
Decedent’s social security no.
Address of person for whom you are acting (number, street, and room or suite no.)
City or town, state, and ZIP code (If a foreign address, see instructions.)
Fiduciary’s name
Address of fiduciary (number, street, and room or suite no.)
City or town, state, and ZIP code
Telephone number (optional)
(
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Section A. Authority
1
Authority for fiduciary relationship. Check applicable box:
a
Court appointment of testate estate (valid will exists)
b
Court appointment of intestate estate (no valid will exists)
c
Court appointment as guardian or conservator
d
Valid trust instrument and amendments
e
Bankruptcy or assignment for the benefit or creditors
f
Other. Describe
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2 a
If box 1a or 1b is checked, enter the date of death
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b
If box 1c—1f is checked, enter the date of appointment, taking office, or assignment or transfer of assets
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Section B. Nature of Liability and Tax Notices
3
Type of taxes (check all that apply):
Income
Gift
Estate
Generation-skipping transfer
Employment
Excise
Other (describe)
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4
Federal tax form number (check all that apply): a
706 series b
709
c
940
d
941, 943, 944
e
1040, 1040-A, or 1040-EZ
f
1041
g
1120 h
Other (list)
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5
If your authority as a fiduciary does not cover all years or tax periods, check here .
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and list the specific years or periods
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For Paperwork Reduction Act and Privacy Act Notice, see separate instructions.
Cat. No. 16375I
Form
(Rev. 11-2017)