Claim for Deficiency Dividends Deductions by a Personal Holding Company, Regulated Investment Company, or Real Estate Investment Trust

• Legal Form Number: 976
• Year: 2022
• Issuer: Treasury Department
• Section: Treasury Department

Form 976

(Rev. November 2022)

Claim for Deficiency Dividends Deductions by a

Personal Holding Company, Regulated Investment

Company, or Real Estate Investment Trust

Department of the Treasury

Internal Revenue Service

(Under Section 547 or 860 of the Internal Revenue Code)

OMB No. 1545-0123

Name of entity

Number, street, and room or suite no. (If a P.O. box, see instructions.)

City or town, state, and ZIP code

Employer identification number

Type of entity filing the claim:

Personal holding company

Regulated investment company

Real estate investment trust

1 Amount of tax deficiency . . . . . . . . . . . . . . . . . . . . . . . 1

2 Tax year of deficiency ends: / / .

3 a Amount paid ........................... 3a

bDate paid / / .

4 Amount unpaid. Subtract line 3a from line 1 . . . . . . . . . . . . . . . . 4

5 How was the deficiency established?

aTax Court Decision—Attach a copy.

b Court Judgment—Attach a copy. If established by a final judgment in a suit against the

United States for refund:

(1) Date the claim for refund was filed / / .

(2) Date the suit was brought / / .

cClosing agreement under section 7121.

d If a personal holding company, agreement under section 547(c)(3)—Attach a copy of a

properly executed Form 2198.

e If a regulated investment company or real estate investment trust, agreement under section

860(e)(3)—Attach a copy of the agreement.

f If a regulated investment company or real estate investment trust, a statement under

section 860(e)(4)—Attach a copy of the Form 8927 filed with the IRS (see instructions).

6 Determination date (see instructions) / / .

7

Date the deficiency dividend was distributed

/ / .

(Attach a certified copy of the

resolution of the board of directors or other authority authorizing the payment of the deficiency dividend.)

8 Deficiency dividend was distributed as follows:

aCash ............................. 8a

bOther property (attach description):

(1) Fair market value ........................ 8b(1)

(2) Adjusted basis ......................... 8b(2)

9 a Amount claimed as a deduction for deficiency dividends . . . . . . . . . . . . 9a

b For a regulated investment company or real estate investment trust, enter the amount of line

9a designated or reported as capital gain dividends . . . . . . . . . . . . . . 9b

10 Only personal holding companies must complete line 10.

(a) Name and address of each shareholder

(b) Class of stock and number of

shares of each class of stock held at

date of payment of deficiency dividend

(c) Amount of deficiency dividend

paid to each shareholder on each

class of stock

Sign

Here

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the best of my knowledge and

belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature of officer Date Title

Paid

Preparer

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if

self-employed

PTIN

Firm’s name Firm’s EIN

Firm’s address Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 17061B Form 976 (Rev. 11-2022)