IRS Form 13656 "Notice of Election by Executive and Related Person to Participate in Announcement 2005-19 Settlement Initiative"

IRS Form 13656 is a U.S. Department of the Treasury - Internal Revenue Service form also known as the "Irs Form 13656 "notice Of Election By Executive And Related Person To Participate In Announcement 2005-19 Settlement Initiative"". The latest edition of the form was released in March 1, 2005 and is available for digital filing.

Download a PDF version of the IRS Form 13656 down below or find it on U.S. Department of the Treasury - Internal Revenue Service Forms website.

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Download IRS Form 13656 "Notice of Election by Executive and Related Person to Participate in Announcement 2005-19 Settlement Initiative"

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