Form 56-F Notice Concerning Feduciary Relationship of Financial In

56-F

Department of the Treasury
Internal Revenue Service

Part I

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Notice Concerning Fiduciary Relationship
of Financial Institution

Form
(Rev. December 2009)

(Internal Revenue Code sections 6036 and 6903)

Identification

1

Name of person for whom you are acting (as shown on the tax return)

3

Address of financial institution (number, street, and room or suite no.)

4

City, state, and ZIP code

2

Employer identification number

5

Telephone no.
(

Bank

)

Thrift

6

Check the applicable box for the type of financial institution:

7
8

if the financial institution is insolvent.
Check here 
Enter the ending date of the financial institution’s tax year (mo., day, yr.)



9

Fiduciary’s name

10

Contact person

13

Telephone no.

11

Address of fiduciary (number, street, and room or suite no.)

12

City or town, state, and ZIP code

14

Check the applicable box if the fiduciary is a:

(

Receiver

Conservator


)

15

if the financial institution is or was a member of a group filing a consolidated return and complete lines 16 to 21 below: Lines 16
Check this box
through 21 are to be completed only if the financial institution is or was a member of a group filing a consolidated return.

16

Name of person for whom you are acting (as shown on the tax return)

18

Address of the common parent (number, street, and room or suite no.)

19

City, state, and ZIP code

20
21

if a copy of this form has been sent to the common parent of the group.
Check here 
Enter the tax year(s) that the financial institution is or was a member of the consolidated group

a
c
e



Evidence of fiduciary authority. Check applicable box(es), and attach copy of applicable orders:
Appointment of conservator
b
Replacement of conservator
Appointment of receiver
d
Order of insolvency
Other evidence of creation of fiduciary relationship (describe) 

Part III
23

Employer identification number

Authority

Part II
22

17

Tax Notices

All notices and other written communications with regard to income, employment, and excise taxes of the financial institution (listed
on line 1) will be addressed to the fiduciary. Indicate below if other notices and written communications should be addressed to the
fiduciary. Include the type of tax, tax periods or years involved.

Part IV

Revocation or Termination of Notice
Section A—Total Revocation or Termination

24
a
b
c

Evidence of termination or revocation of fiduciary authority (Check applicable box(es)):
Certified copy of court order revoking fiduciary authority attached.
Copy of certificate of dissolution or termination of a business entity attached.
Other evidence of termination of fiduciary relationship (describe) 
I certify that I have the authority to execute this notice concerning fiduciary relationship on behalf of the taxpayer.

Please
Sign
Here



Fiduciary’s signature

Title, if applicable
Cat. No. 12784J

Date
Form

56-F

(Rev. 12-2009)