~~ 56 Notice Concerning Fiduciary Relationship ‘owe No, 1945-0018 ia Ronee (intemsi Revenue Code sections 6036 and 6905) EXM centification ‘re 0 pereon fo whom ou areata a crown onthe oxen) Tdentving umber Dessdents esa a, FIRST MIDDLE LAST SSN~HK- HHH ‘aes of pars Tor ory You re ag PURER GE, nd FOOM oF BRE TO GENERAL DELIVERY c/o 1234 Post Office Address {iyo tow, stk, ond 2P code [a orig arose, se nsrone) City / Town, State [12345] ‘supply city and ZIP code of your local post office Fins rae STEVEN MNUCHIN, SECRETARY OF THE U.S. TREASURY ‘Ress of feucany(rumiber see, nd rom or ute ne) 1500 PENNSYLVANIA AVE. NW Bip own, se IP coe Tagan rab otra WASHINGTON, DC 20220 3 Authority 1+ Authonty for teieary eationshp. Check appiable bo a1) C1 Will and codieils or court order appointing fiduciary (2) Date of death bit) C) Court order appointing tieuciary (2) Date (see instructions) © Ol Velie trust instrument ane amendments [Kl Other, Deserbe » Appointment of Fiduciary DEBTOR & Creditor Nature of Liability and Tax Notices ‘Type of tax (estate, gift, generation-skipping transfer, income, excise, etc) & Withholding Returns, Federal tax form number (708, 1040, 1041, 1120, etc) & 1040, 1040-V, 1099-R, 1099-C, 1099-oTD Year(s) or periods) (f estate tax, date of death) BIRTH YRAR 2020 Ifthe fiduciary listed in Part | is the person to whom notices and other written communications should be sent or all items dosctibed on linas 2,8, and 4, check here... ss Se »oO 6 Ifthe fiduciary listed in Par | is the person to whom notices and other written communications should be sent for some (out not all) of the ams described on ines 2, 8, and 4, chack hore band list the applicable Federal tax form numivor and the years) oF Penoo(s) applicable EXMETE Revocation or Termination of Notice ‘Section A—Total Revocation or Termination, 7 Chock this box if you aro revoking or torminating all prior notioes concerning fiduciary relationships on fll with the Internal Rovenue Service for the same tax malters and years of pariocs covered by this notice concerning fiduciary relationship. & C1 RRoason for terination of fiduciary elationship. Chock applicable box: O Cout order revoking fiduciary authority Certificate of dissolution or termination of a business entity Bother. Describe > oe ‘Section B—Parlial Revocation a Check this box f you are raving earter notions concerning fckciary relationships on tis withthe intemal Hevanus Service for ‘ne same tax matter ana yous & parods covered by ins netics canceming Hauclary rlaonship > Oo b Specty to whom granted, dato, ane addrass, nekcing ZIP cod. » Section O—Subsiitute Fiduciary Chock this box If anew fiduciary oF fduclavies have been or will be substituted for the revoking or terminating fiduclary and specify the name(s} and adcress(es), including ZIP code(s}, of the new fiduciaryies). os >o > For Paperwork Reduction Act and Privacy Act Nolice, see back page. (cat Nn. 15751 Form 56 qo. 7.2008Form 95 dee 7.2000) Page 2 Court and Administrative Proceedings ‘Nae of cout OT oter thay a cout proceeding, endl he ype of proceeding nd rams OF RNC Date procesone ita NAME OF COURT (IF APPLICABLE) DATE OF INDICTMENT ‘asress of court Docket ruber of zroooeang 1234 COURT ADDRESS st. CASE NUMBER {Gyo town, site, ana ZP ode Dae Time am] Pa tone pomadias crTy / TOWN, ST_12345 DATE | TIME om Signature Tei lave Ws wT ee Wi LG CONG Fa NS on DT ATS Please ‘Sign r- Authorized Here Fest. Middle Representative TODAY'S DATE Faas sana Teepe Bie Fem 56 tow 7-2008