Form 8971
(January 2016)
Department of the Treasury
Internal Revenue Service
Information Regarding Beneficiaries
Acquiring Property From a Decedent
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Information about Form 8971 and its separate instructions is at www.irs.gov/form8971.
OMB No. 1545-2264
Check box if this is a supplemental filing
Part I
Decedent and Executor Information
1 Decedent's name 2 Decedent's date of death
3 Decedent's SSN
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.
A
Name of Beneficiary
B
TIN
C
Address, City, State, ZIP
D
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.
Sign
Here
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
belief, all information reported herein is true, correct, and complete.
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Signature of executor
Date
May the IRS discuss this return with the preparer shown below? See instructions . . . . . . . . . . . . . .
Yes
No
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer’s signature Date
Check if
self-employed
PTIN
Firm’s name
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Firm’s address
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Firm’s EIN
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Phone no.
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 37794V
Form 8971 (1-2016)
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