8971
Information Regarding Beneficiaries
Form
Acquiring Property From a Decedent
OMB No. 1545-2264
(January 2016)
Department of the Treasury
Information about Form 8971 and its separate instructions is at
▶
Internal Revenue Service
Check box if this is a supplemental filing
Part I
Decedent and Executor Information
3 Decedent's SSN
1 Decedent's name
2 Decedent's date of death
4 Executor's name (see instructions)
5 Executor's phone no.
6 Executor's TIN
7 Executor's address (number and street including apartment or suite no.; city, town, or post office; state or province; country; and
ZIP or foreign postal code)
8 If there are multiple executors, check here
and attach a statement showing the names, addresses, telephone numbers, and
TINs of the additional executors.
9 If the estate elected alternate valuation, indicate the alternate valuation date:
Part II
Beneficiary Information
How many beneficiaries received (or are expected to receive) property from the estate?
For each beneficiary, provide
the information requested below. If more space is needed, attach a statement showing the requested information for the additional
beneficiaries.
C
A
B
D
Name of Beneficiary
TIN
Address, City, State, ZIP
Date Provided
Notice to Executors:
Submit Form 8971 with a copy of each completed Schedule A to the IRS. To protect privacy, Form 8971 should not be provided to any
beneficiary. Only Schedule A of Form 8971 should be provided to the beneficiary. Retain copies of all forms for the estate's records.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
Sign
belief, all information reported herein is true, correct, and complete.
Here
Signature of executor
Date
May the IRS discuss this return with the preparer shown below? See instructions
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Yes
No
Print/Type preparer’s name
Preparer’s signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
Firm’s EIN
▶
▶
Use Only
Firm’s address
Phone no.
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8971
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Form
(1-2016)
Cat. No. 37794V