Form (January 2016) Department of the Treasury Internal Revenue Service 8971 Information Regarding Beneficiaries Acquiring Property From a Decedent OMB No. 1545-2264 Information about Form 8971 and its separate instructions is at www.irs.gov/form8971. Check box if this is a supplemental filing Part I Decedent and Executor Information 2 Decedent's date of death 1 Decedent's name 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 TINs of the additional executors. and attach a statement showing the names, addresses, telephone numbers, and 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. Signature of executor Date May the IRS discuss this return with the preparer shown below? See instructions . . . . . . Date . . . . . . . . Yes PTIN No Paid Preparer Use Only Print/Type preparer's name Preparer's signature Check if self-employed Firm's EIN Phone no. Firm's name Firm's address For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 37794V Form 8971 (1-2016) American LegalNet, Inc. www.FormsWorkFlow.com [This page left blank intentionally] American LegalNet, Inc. www.FormsWorkFlow.com Form 8971 (1-2016) SCHEDULE A--Information Regarding Beneficiaries Acquiring Property From a Decedent Information about Form 8971 (including Schedule A) and its separate instructions is at www.irs.gov/form8971. Check box if this is a supplemental filing Part 1. General Information 1 Decedent's name 5 Executor's name 7 Executor's address 2 Decedent's SSN 3 Beneficiary's name 4 Beneficiary's TIN 6 Executor's phone no. Part 2. Information on Property Acquired A Item No. B Description of property acquired from the decedent and the Schedule and item number where reported on the decedent's Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return. If the beneficiary acquired a partial interest in the property, indicate the interest acquired here. C Did this asset increase estate tax liability? (Y/N) D Valuation Date E Estate Tax Value (in U.S. dollars) Form 706, Schedule Description -- , Item Notice to Beneficiaries: You have received this schedule to inform you of the value of property you received from the estate of the decedent named above. Retain this schedule for tax reporting purposes. If the property increased the estate tax liability, Internal Revenue Code section 1014(f) applies, requiring the consistent reporting of basis information. For more information on determining basis, see IRC section 1014 and/or consult a tax professional. Page A-1 American LegalNet, Inc. www.FormsWorkFlow.com Page Form 8971 (1-2016) of SCHEDULE A--Continuation Sheet Use only if you need additional space to report property acquired (or expected to be acquired) by the beneficiary. Check box if this is a supplemental filing Part 1. General Information 1 Decedent's name 5 Executor's name 7 Executor's address 2 Decedent's SSN 3 Beneficiary's name 4 Beneficiary's TIN 6 Executor's phone no. Part 2. Information on Property Acquired A Item No. (continue from previous page) B Description of property acquired from the decedent and the Schedule and item number where reported on the decedent's Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return. If the beneficiary acquired a partial interest in the property, indicate the interest acquired here. C Did this asset increase estate tax liability? (Y/N) D Valuation Date E Estate Tax Value (in U.S. dollars) Notice to Beneficiaries: You have received this schedule to inform you of the value of property you received from the estate of the decedent named above. Retain this schedule for tax reporting purposes. If the property increased the estate tax liability, Internal Revenue Code section 1014(f) applies, requiring the consistent reporting of basis information. For more information on determining basis, see IRC section 1014 and/or consult a tax professional. Page A-2 American LegalNet, Inc. www.FormsWorkFlow.com