Form Tc-41db - Statement Of Dependent Beneficiary Income
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1TC-41DB
Statement of Dependent Beneficiary Income
Rev. 12/13
This form is required by Utah Code Section 59-10-1402(17).
I, the undersigned, hereby declare that, for the taxable year ending _____/_____/ 20_____, I have or will claim the
dependency exemption on my federal income tax return under Internal Revenue Code Section 151 for:
Name of dependent beneficiary
Dependant’s Social Security Number
I attest that the dependent named above is a beneficiary of a trust that is a pass-through entity, and that the dependent’s
federal adjusted gross income for the taxable year does not exceed the basic standard deduction calculated under
Internal Revenue Code Section 63 for the taxable year.
Signature
Date signed
Print name
Taxpayer’s Social Security Number
Instructions:
▪
Give this form to the fiduciary of the estate or trust.
▪
Keep a copy with your tax records.
▪
Do not
send a copy of this form to the Tax Commission.
▪
This statement must be retained by the trustee of the trust and made available to the Tax Commission, upon
request, per Utah Code Section 59-10-1403(6).
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Parent category: Financial