Schedule Cc - Request For A Closing Certificate For Fiduciaries - 2012 Page 2
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1
2 Schedule CC
Page 2
2012
Information Required When Requesting a Closing Certificate for Trusts
PART II
Complete lines 1 through 9 and sign below.
1. Enclose a copy of the trust instrument with amendments (will /codicils) and copies of annual court accountings for past
three years.
2. a. Name(s) of grantor(s)
Social security number(s)
b. Name(s) of grantee(s)
Social security number(s)
3. On what date was the trust funded?
4. Was the trust contacted by the IRS and/or Wis. Dept. of Revenue in the last 3 years?
Yes
No
If Yes, explain:
5. a. State reason for closing the trust
b. If death of beneficiary, provide name of beneficiary, social security number, last address, and date of death.
6. Have you petitioned the court to close the trust?
Yes
No
If Yes, enclose a copy of the petition.
If No, explain why no petition has been filed
7. Has the trust made an annual accounting to a court?
Yes
No
If No, explain
8. Is a certificate required by the court?
Yes
No
See page 15 of the Form 2 instructions
9. Enter the total fair market value of each of the assets listed below that are held by the trust at the end of the year preceding the
final year of the trust. (NOTE Where any line from 9a through 9f is left blank, it will be deemed that NONE is the DECLARATION
for that line by the person(s) signing Schedule CC.)
a. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a
.00
b. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9b
.00
.00
c. Mortgages, Notes, and Cash . . . . . . . . . . . . . . . . . . . . . . 9c
d. Annuities and Life Insurance . . . . . . . . . . . . . . . . . . . . . . 9d
.00
e. Interest in Partnerships, LLCs, and S Corporations . . . . . 9e
.00
f. Other Miscellaneous Property . . . . . . . . . . . . . . . . . . . . . 9f
.00
.00
g. Total Assets (add lines 9a through 9f) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9g
I, as fiduciary, declare under penalties of law that I have examined this schedule (including accompanying documents and statements)
and to the best of my knowledge and belief it is true, correct, and complete.
Your signature
Date
Daytime phone
(
)
PERSON PREPARING FORM (Individual or firm) if other than the preceding signer
Name
Signature of preparer
Date
Daytime phone
(
)
Mail to: Wisconsin Department of Revenue
PO Box 8918
Madison WI 53708-8918
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