Schedule C-1 (Form Rev-1505 Ex+) - Closely-Held Corporate Stock Information Report
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1REV-1505 EX+ (11-11)
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
START
1. Name of Corporation _____________________________________________________ State of Incorporation
Address _______________________________________________________________ Date of Incorporation
City ________________________________________ State_____ ZIP Code_________ Total Number of Shareholders
2. Federal Employer ID Number _____________________________________________ Business Reporting Year
3. Type of Business __________________________________________ Product/Service
4.
TYPE
TOTAL NUMBER OF
NUMBER OF SHARES
VALUE OF THE
STOCK
PAR VALUE
Voting/Non-Voting
SHARES OUTSTANDING
OWNED BY THE DECEDENT
DECEDENT’S STOCK
Common
$
Preferred
$
Provide all rights and restrictions pretaining to each class of stock.
o
o
5. Was the decedent employed by the corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, Position _______________________________ Annual Salary $______________ Time Devoted to Business
o
o
6. Was the corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, provide amount of indebtedness $
o
o
7. Was there life insurance payable to the corporation upon the death of the decedent? . . . . .
Yes
No
If yes, Cash Surrender Value $_________________________________ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years
if the date of death was prior to 12-31-82?
o
o
o
o
Yes
No
If yes,
Transfer
Sale
Number of Shares
Transferee or Purchaser ________________________________ Consideration $____________________ Date
Attach a separate sheet for additional transfers and/or sales.
o
o
9. Was there a written shareholderʼs agreement in effect at the time of the decedentʼs death? . . . .
Yes
No
If yes, provide a copy of the agreement.
o
o
10. Was the decedentʼs stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, provide a copy of the agreement of sale, etc.
o
o
11. Was the corporation dissolved or liquidated after the decedentʼs death? . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
o
o
12. Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . .
Yes
No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedentʼs stock.
B. Complete copies of financial statements or federal corporate income tax returns (Form 1120) for the year of death and four preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationships to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedentʼs stock.
(If more space is needed, insert additional sheets of the same size.)
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