Form 56
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Notice Concerning Fiduciary Relationship
(Internal Revenue Code sections 6036 and 6903)
OMB No. 1545-0013
Part I
Identification
Name of person for whom you are acting (as shown on the tax return) Identifying number Decedent’s social security no.
Address of person for whom you are acting (number, street, and room or suite no.)
City or town, state, and ZIP code (If a foreign address, see instructions.)
Fiduciary’s name
Address of fiduciary (number, street, and room or suite no.)
City or town, state, and ZIP code
Telephone number (optional)
( )
Section A. Authority
1 Authority for fiduciary relationship. Check applicable box:
a
Court appointment of testate estate (valid will exists)
b
Court appointment of intestate estate (no valid will exists)
c
Court appointment as guardian or conservator
d
Valid trust instrument and amendments
e
Bankruptcy or assignment for the benefit or creditors
f
Other. Describe
2 a If box 1a or 1b is checked, enter the date of death
2 b If box 1c—1f is checked, enter the date of appointment, taking office, or assignment or transfer of assets
Section B. Nature of Liability and Tax Notices
3 Type of taxes (check all that apply):
Income Gift Estate Generation-skipping transfer Employment
Excise Other (describe)
4 Federal tax form number (check all that apply): a 706 series b 709 c 940 d 941, 943, 944
e
1040, 1040-A, or 1040-EZ f 1041 g 1120 h Other (list)
5
If your authority as a fiduciary does not cover all years or tax periods, check here . . . . . . . . . . . . .
and list the specific years or periods
6
If the fiduciary listed wants a copy of notices or other written communications (see the instructions) check this box . . . .
and enter the year(s) or period(s) for the corresponding line 4 item checked. If more than 1 form entered on line 4h, enter the
form number.
Complete only if the line 6 box is checked.
If this item
is checked:
Enter year(s) or period(s)
If this item
is checked:
Enter year(s) or period(s)
4a 4b
4c 4d
4e 4f
4g 4h:
4h: 4h:
For Paperwork Reduction Act and Privacy Act Notice, see the separate instructions.
Cat. No. 16375I
Form 56 (Rev. 12-2011)
DEVINE, PATRICK: SS MORTMAIN ACCOUNT
123456789
123-45-6789
18463 - 208TH AVENUE (True Residential Address - US/SS INDEPENDENT "OFF-SHORE MORTMAIN" TREASURY; PUERTO RICO)
SIGOURNEY, IOWA 52591-8236
PATRICK DEVINE PRIVATE BANK E & T
c/o 18463 -208th Avenue (non-resident)
Sigourney, Iowa 52591-8236
641
541-0035
June 2, 1949
This is the date of Fiduciary Agent's assignment by the issuance of his Individual Banker's EIN.
Mortmain Corporate Usury Income Tax Debt Set-Off with Credits due.
1099A, 1096
Form 56 (Rev. 12-2011)
Page 2
Part II
Court and Administrative Proceedings
Name of court (if other than a court proceeding, identify the type of proceeding and name of agency) Date proceeding initiated
Address of court Docket number of proceeding
City or town, state, and ZIP code
Date Time
a.m.
p.m.
Place of other proceedings
Part III
Signature
Please
Sign
Here
I certify that I have the authority to execute this notice concerning fiduciary relationship on behalf of the taxpayer.
Fiduciary’s signature
Title, if applicable
Date
Form 56 (Rev. 12-2011)
Private - Individual Banker
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