2004 Version =. 56 Notice Concerning Fiduciary Relationship ‘owe No, 1945-0018 ia Reva oes (intemsi Revenue Code sections 6036 and 6905) EXM centification ‘re 0 pereon fo whom ou areata a crown onthe oxen) Tdentving umber Dessdents sek seury a, FIRST MIDDLE LAST SSN-XX-¥RXK ‘aes oF Gar Tor oT You re ag PUREE GE, nd TOON oF Bae TO 1234 YOUR ADDRESS ST, or GENERAL DELIVERY, 1234 POST OFFICE ADDRESS {iyo tow, state, end ZP cod (a oeign aes, se nstucors) CIty / TOWN, ST 12345 Feta 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) C1 Court order appointing tieuciary (2) Date (see instructions) © Al Velie trust instrument ane amendments ¢ [Kl Other. Descrbe » Appointment of Fiduciary DEBTOR & Creditor Nature of Liability and Tax Notices ‘Type of tax (estate, gift, gerevation-skipping transfer, income, excise, tc) Estate Tax, _Tneome Tax Federal tax form number (708, 1040, 1041, 1120, etc) & 1040, 1040-V, 1096, 1099-A, 1099-oTD ‘earls or periods) {estate tax, date of death) » Nunc Pro unc from (BIRTH YEAR] -> Current Ifthe fiduciary listed in Part | is the person to whom notices and other written communications should be sent for 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 Revocation or Termination of Notice Seqlion Ax Total Revocation or Termination 7 Chack this box if you arp revoking or terminating all prior notices eoncecring fduclary relationships on filo with the internal Rovenve Sonice for the same tax matters and years oF poriocs covered by this notice concomning cuciary relationship. & C1] Reason for termination of fiduciary relations. Check applicable box: C1 Gout order revoking fiduciary authority D Gertiticate of cissolution or termination of 8 business entity Other. Describe » Corzecting all records on file Section B—Partial Revocation ‘8a Ghack this box if you are revoking earter notices concerning fiduciary relationships on fle with the Internal Revenue Service for ‘the same tax matters and years or periods Covered by ths notice concerning tdci relationship oO 1b Spocity to whom granted, date, and address, including ZIP code. > oe 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 Tre co aba hana cout rote ae be ronatia anne sao) | ie ORR VITAL “STADISTICS OFFICE YOUR” BIRTH STATE wT BRES'Se RECORD aieaslet iegaetaneats Tosa" viva, _stagzstics aDpRESS* BIRIH CERT. NOMBER Siva om ste wa 2 oe ome ke! noe cITy / TOWN, ST 12345 N/A N/A _pm Signature hi a oe Please a noe |) By: Gin Middle Attorney in Fact TODAY'S DATE Fem 56 tow 7-2008 YOU NEED TO LOCATE THE NAME OF THE OFFICE AND THE ADDRESS FOR VITAL STATISTICS / VITAL RECORDS WHERE YOUR ORIGINAL BIRTH CERTIFICATE IS LOCATED. TSIS IS IN YOUR BIRTH STATE.