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