REV-1505 EX+ (11-11)
                                                                      SCHEDULE C-1
                                                              CLOSELY-HELD CORPORATE
                  INHERITANCE TAX RETURNSTOCK INFORMATION REPORT
                  RESIDENT DECEDENT

START ESTATE OF                                                                                                                       FILE NUMBER
Ü
      1.  Name of Corporation _____________________________________________________ State of Incorporation
      Address _______________________________________________________________                                                                                        Date of Incorporation
      City ________________________________________ State_____ ZIP Code_________ Total Number of Shareholders
      2.  Federal Employer ID Number _____________________________________________                                                                                   Business Reporting Year
      3.  Type of Business __________________________________________ Product/Service 

      4.                      TYPE                TOTAL NUMBER OF                                                             NUMBER OF SHARESVALUE OF THE 
          STOCK Voting/Non-VSHARES OUTSTANDINGoting                                         PAR VALUEOWNED BY THE DECEDENTDECEDENT’S STOCK

          Common                                                                                                                                          $
          Preferred                                                                                                                                       $

                                              Provide all rights and restrictions pretaining to each class of stock.
      5.  Was the decedent employed by the corporation?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .o. .                 Yes  oNo
      If yes, Position _______________________________ Annual Salary  $______________ Time Devoted to Business
      6.  Was the corporation indebted to the decedent?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .o. .               Yes  oNo
      If yes, provide amount of indebtedness $
      7.  Was there life insurance payable to the corporation upon the death of the decedent?  . . . .o.                                     Yes  oNo
      If yes, Cash Surrender Value $_________________________________ Net proceeds payable $
      Owner of the policy
      8.  Did the decedent sell or transfer stock in this company within one year prior to death or within two years 
      if the date of death was prior to 12-31-82?
      oYes  o No                   If yes,   Transfer  o    Saleo                                     Number of Shares
      Transferee or Purchaser  ________________________________ Consideration $____________________ Date
      Attach a separate sheet for additional transfers and/or sales.
      9.  Was there a written shareholderʼs agreement in effect at the time of the decedentʼs death? oYes  . . . .                                oNo
      If yes, provide a copy of the agreement.
      10. Was the decedentʼs stock sold?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .o. . .Yes  . .oNo
      If yes, provide a copy of the agreement of sale, etc.
      11. Was the corporation dissolved or liquidated after the decedentʼs death?  . . . . . . . . . . . . . . . . .o. .Yes  .                    oNo
      If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
      12. Did the corporation have an interest in other corporations or partnerships?  . . . . . . . . . . . . .                        oYes  oNo
      If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.

                              THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
      A.  Detailed calculations used in the valuation of the decedentʼs stock.
      B.  Complete copies of financial statements or federal corporate income tax returns (Form 1120) for the year of death and four preceding years.
      C.  If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
      been secured, attach copies.
      D.  List of principal stockholders at the date of death, number of shares held and their relationships to the decedent.
      E.  List of officers, their salaries, bonuses and any other benefits received from the corporation.
      F.  Statement of dividends paid each year. List those declared and unpaid.
      G.  Any other information relating to the valuation of the decedentʼs stock.
                                                  (If more space is needed, insert additional sheets of the same size.)
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