Form 56-F - Notice Concerning Fiduciary Relationship Of Financial Institution
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1
256-F
Notice Concerning Fiduciary Relationship
OMB No. 1545-2159
Form
(Rev. December 2009)
of Financial Institution
For IRS Use Only
Department of the Treasury
(Internal Revenue Code sections 6036, 6402, and 6903)
Internal Revenue Service
Part I
Identification
1
Name of person for whom you are acting (as shown on the tax return)
2
Employer identification number
3
Address of financial institution (number, street, and room or suite no.)
5
4
City, state, and ZIP code
Telephone no.
(
)
6
Check the applicable box for the type of financial institution:
Bank
Thrift
7
Check here
if the financial institution is insolvent.
8
Enter the ending date of the financial institution’s tax year (mo., day, yr.)
9
Fiduciary’s name
10
Contact person
11
Address of fiduciary (number, street, and room or suite no.)
12
City or town, state, and ZIP code
13
Telephone no.
(
)
14
Check the applicable box if the fiduciary is a:
Receiver
Conservator
15
Check this box
if the financial institution is or was a member of a group filing a consolidated return and complete lines 16 to 21 below: Lines 16
through 21 are to be completed only if the financial institution is or was a member of a group filing a consolidated return.
16
Name of person for whom you are acting (as shown on the tax return)
17
Employer identification number
18
Address of the common parent (number, street, and room or suite no.)
19
City, state, and ZIP code
20
Check here
if a copy of this form has been sent to the common parent of the group.
21
Enter the tax year(s) that the financial institution is or was a member of the consolidated group
Authority
Part II
22
Evidence of fiduciary authority. Check applicable box(es), and attach copy of applicable orders:
a
Appointment of conservator
b
Replacement of conservator
c
Appointment of receiver
d
Order of insolvency
e
Other evidence of creation of fiduciary relationship (describe)
Part III
Tax Notices
23
All notices and other written communications with regard to income, employment, and excise taxes of the financial institution (listed
on line 1) will be addressed to the fiduciary. Indicate below if other notices and written communications should be addressed to the
fiduciary. Include the type of tax, tax periods or years involved.
Part IV
Revocation or Termination of Notice
Section A—Total Revocation or Termination
24
Evidence of termination or revocation of fiduciary authority (Check applicable box(es)):
a
Certified copy of court order revoking fiduciary authority attached.
b
Copy of certificate of dissolution or termination of a business entity attached.
c
Other evidence of termination of fiduciary relationship (describe)
I certify that I have the authority to execute this notice concerning fiduciary relationship on behalf of the taxpayer.
Please
Sign
Here
Fiduciary’s signature
Title, if applicable
Date
56-F
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 12784J
Form
(Rev. 12-2009)
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