976
Claim for Deficiency Dividends Deductions by a
Personal Holding Company, Regulated Investment
Form
OMB No. 1545-0123
Company, or Real Estate Investment Trust
(Rev. November 2014)
Department of the Treasury
(Under Section 547 or 860 of the Internal Revenue Code)
Internal Revenue Service
Name of entity
Employer identification number
Type of entity filing the claim:
Number, street, and room or suite no. (If a P.O. box, see instructions.)
Personal holding company
City or town, state, and ZIP code
Regulated investment company
Real estate investment trust
1
1
Amount of tax deficiency .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2
Tax year of deficiency ends:
/
/
.
3 a Amount paid .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3a
b Date paid
/
/
.
4
4
Amount unpaid. Subtract line 3a from line 1
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
5
How was the deficiency established?
a
Tax Court Decision—Attach a copy.
b
Court Judgment—Attach a copy. If established by a final judgment in a suit against the
United States for refund:
(1) Date the claim for refund was filed
/
/
.
(2) Date the suit was brought
/
/
.
c
Closing agreement under section 7121.
d
If a personal holding company, agreement under section 547(c)(3)—Attach a copy of a
properly executed Form 2198.
e
If a regulated investment company or real estate investment trust, agreement under section
860(e)(3)—Attach a copy of the agreement.
f
If a regulated investment company or real estate investment trust, a statement under
section 860(e)(4)—Attach a copy of the Form 8927 filed with the IRS (see instructions).
6
Determination date (see instructions)
/
/
.
7
Date the deficiency dividend was distributed
(Attach a certified copy of the
/
/
.
resolution of the board of directors or other authority authorizing the payment of the deficiency dividend.)
8
Deficiency dividend was distributed as follows:
a Cash
8a
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
b Other property (attach description):
(1) Fair market value .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
8b(1)
(2) Adjusted basis .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
8b(2)
9 a Amount claimed as a deduction for deficiency dividends
9a
.
.
.
.
.
.
.
.
.
.
.
.
b For a regulated investment company or real estate investment trust, enter the amount of line
9a designated or reported as capital gain dividends .
.
.
.
.
.
.
.
.
.
.
.
.
.
9b
10 Only personal holding companies must complete line 10.
(b) Class of stock and number of
(c) Amount of deficiency dividend
(a) Name and address of each shareholder
shares of each class of stock held at
paid to each shareholder on each
date of payment of deficiency dividend
class of stock
Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the best of my knowledge and
Sign
belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here
Signature of officer
Date
Title
Print/Type preparer’s name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Use Only
Firm’s name
Firm's EIN
▶
▶
Firm's address
Phone no.
▶
976
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 11-2014)
Cat. No. 17061B