Department of the Treasury — Internal Revenue Service
Form 13656
Notice of Election by Executive and Related Person to
Participate in Announcement 2005-19 Settlement Initiative
(March 2005)
NOTE: The Service can decline to execute a closing agreement with any party that fails to provide all
information requested within this Form 13656.
Section I. Executive Information
1. Executive name (and name of spouse, if joint return) 2. Social security number (SSN)
(Executive)
(Spouse)
3. Address (Street, City, State, ZIP code) 4. Daytime telephone number
5. FAX number
6. Executive currently is in Appeals or Examination 7. Executive has executed a Power of Attorney
NoYes (Please complete items 8 and 9.) No Yes (Please attach a copy.)
8. Name and address (Street, City, State, ZIP code) of Appeals Officer or Agent
I elect to participate in the settlement initiative as described in Announcement 2005-19
and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005. I am
submitting with this election the information and documents requested. Under penalties
of perjury, I declare that I have examined this Form 13656 and to the best of my
knowledge and belief, it is true, correct and complete.
Executive
Attestation
Signature of Executive Date
Related Person InformationSection II.
2. Related Person identification1. Name of Related Person to which stock options or restricted stock were transferred
4. Daytime telephone number3. Address (Street, City, State, ZIP code)
5. FAX number
NoYes (Please attach a copy.)
6. Related Person has executed a Power of Attorney
Catalog No. 39565K
Sheet 1 of 4
Form 13656 (3-2005)
www.irs.gov
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( )
9. Daytime telephone number
( )
number (EIN)
( )
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signature
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Section II. Related Person Information — continued
Related Person Attestation
All partners/members of the Related Person elect to participate in the settlement initiative as described in
Announcement 2005-19 and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005.
Under penalties of perjury, I declare that I have examined this Form 13656 and to the best of my
knowledge and belief, it is true, correct and complete.
DateName (Please print.) Signature
1 .
DateName (Please print.) Signature
2.
DateSignatureName (Please print.)
3.
DateSignatureName (Please print.)
4.
DateName (Please print.) Signature
5.
Signature DateName (Please print.)
6.
DateName (Please print.) Signature
7.
DateName (Please print.) Signature
8.
Corporation InformationSection III.
1. Name of corporation that issued the stock options or restricted stock 2. Corporation identification
3. Address (Street, City, State, ZIP code) 4. Daytime telephone number
5. FAX number
6. Is the corporation electing to participate in this settlement initiative? NoYes Unknown
7. Name of corporation that received the services from the Executive (if different from the 8. Corporation identification
9. Address (Street, City, State, ZIP code)
Department of the Treasury – Internal Revenue Service
number (EIN)
corporation named in Section III, Item 1)
number (EIN)
10. Daytime telephone number
11. FAX number
Catalog No. 39565K
Sheet 2 of 4
Form 13656 (3-2005)
www.irs.gov
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Information and Documentation Required to Process Election by
Executive and Related Person
Section IV.
Answer the following questions and provide the listed documentation. If you need additional space for your answers,
please attach additional sheets and identify the continued answers by item number. “Provide documentation” means
“Attach copies of documents that verify your responses.”
What did the Related Person transfer to the Executive in exchange for the stock options or restricted stock the Executive
transferred to the Related Person? On what date(s) did the transfer or sale occur? Provide documentation (including copies of any
promissory notes and appraisal reports).
On what date(s) did the Related Person exercise stock options it received from the Executive? Does the Related Person still hold
options it has not exercised?
What was the fair market value of the stock on the exercise date or the date of vesting? Provide documentation.
Has the Related Person paid any amounts (including interest) to
the Executive?
Did the Related Person or the Executive pay any transaction
costs (including promoter, accounting, appraisal, and legal fees)?
Has the Related Person sold all the stock it acquired through this transaction (including stock acquired by exercising options)?
NoYes (See below.)
For any stock sold, provide a schedule listing the number of shares sold, the date of sale, the sales price, and the claimed basis
at the date of sale. Provide documentation.
Provide copies of all promotional packages, legal opinions, or engagement letters obtained by the Executive or the Related Person
(or any person acting on their behalf) pertaining to this transaction.
Provide the name, address, and telephone number of the entity and person(s) that sold or promoted the sale of the transaction
described in Announcement 2005-19 to the Executive or the Related Person.
Provide a computation of any tax and penalty due from the Executive under the terms of Announcement 2005-19.
Provide a computation of the Related Person's basis in stock still held pursuant to Announcement 2005-19.
1.
2.
(Or, on what date did the restricted stock vest?)
Yes No
3.
Yes (Provide documentation of all payments.)
No
4.
Yes (Provide documentation of all payments.)
No
5.
Note:
6.
7.
8.
9.
Department of the Treasury – Internal Revenue Service
Catalog No. 39565K
Sheet 3 of 4
Form 13656 (3-2005)
www.irs.gov
Information and Documentation Required to Process Election by
Executive and Related Person
Section IV. — continued
Provide a computation of any change in the tax liability of the Related Person as a result of this Election.
Provide copies of all federal tax returns filed by the Related
Person and the Executive from the date the options or
restricted stock was transferred to the Related Person to the
present.
Is the Executive or Related Person currently in tax litigation
with the government?
Yes No
Provide a schedule listing the names, addresses, and SSNs
of the following:
Has the Executive filed a Qualified Amended Return (as defined
by Treas. Reg. §1.6664-2(c)(3)) pertaining to the transaction?
a.
Yes (Provide a copy.)
The spouses of partners or other members of pass-
through entities who filed joint returns for any taxable
period affected by the terms of the settlement.
Has the Executive or the Related Person received a Form W-2
or Form 1099 pertaining to the transaction?
Has the Executive filed a disclosure statement pertaining
to the transaction pursuant to Announcement 2002-2?
Instructions
Send your completed Form 13656 to:
Internal Revenue Service
ATTN: Announcement 2005-19
MC 4166 NWSAT
4050 Alpha Road
Farmers Branch, TX 75244
If you are under examination or in Appeals, please
provide a copy of this Notice of Election to the
examining revenue agent or the Appeals Officer.
10.
11. 12.
13. 14.
15. 16.
No
All partners or members of the Related Person and
b.
Yes (Provide a copy.) No Yes (Provide a copy of all forms.) No
1.
2.
(Provide a copy of the complaint
or the Tax Court petition.)
Department of the Treasury – Internal Revenue Service
Catalog No. 39565K
Sheet 4 of 4
Form 13656 (3-2005)
www.irs.gov
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