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                                                                                                                               OMB No. 1545-0432
                            Request for Discharge From Personal Liability Under 
Form  5495                                                                                                                     For IRS Use Only
(Rev. December 2008)              Internal Revenue Code Section 2204 or 6905
Department of the Treasury                                  ▶  See instructions on back.
Internal Revenue Service 
Decedent’s name                                                                                     Date of death  Social security number 

Requester’s name                                                                                                   Kind of Tax 

Title                                                                                                              Income 
                                                                                                                   Gift 
Number, street, and room or suite no. (If a P.O. box, see instructions.) 
                                                                                                                   Estate
City, town, or post office, state, and ZIP code                                                                    Daytime phone number 

                            Tax Returns for Which Discharge From Personal Liability is Requested 
      Form                  Tax Period          SSN/EIN on                       Name and Address                 Service Center         Date 
      Number                Ended               Return                           Shown on Return                   Where Filed          Filed 

If applicable, provide the name of the decedent’s spouse (surviving or deceased)                                   Spouse’s social security number 

I have attached the items checked to help expedite action on my request. 
Copies of returns listed above. 
Copies of letters of administration or letters testamentary. 
Other (describe): 

I request a discharge from personal liability for any deficiency for the kind of tax and periods shown above, as provided by section 2204 
      or 6905 of the Internal Revenue Code. 
      Under penalties of perjury, I declare that I have examined this request, including accompanying schedules and statements, and to the best of my 
      knowledge and belief, it is true, correct, and complete. 
Sign             I certify that I have never been assessed any penalties for civil fraud for any federal or state tax matter nor have I been charged with,  
                 indicted for, or convicted of fraud. If you cannot certify this statement, attach a detailed statement explaining the circumstances 
Here             under which you were assessed a penalty, charged with, indicted for, or convicted of fraud. 
      ▲                                                                                                           ▲
                 Signature of requester                                                 Date                       Identifying number 
For Privacy Act and Paperwork Reduction Act Notice, see back of form.                   Cat. No. 42571S            Form  5495  (Rev. 12-2008) 



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Form 5495 (Rev. 12-2008)                                                                                                    Page 2 
Information and Instructions                                      Privacy Act and Paperwork Reduction Act Notice. 
                                                                  We ask for the information on this form to carry out the  
General Information                                               Internal Revenue laws of the United States. We collect  
Ordinarily, the IRS has 3 years after an income tax, gift         this information under the authority of Internal Revenue  
tax, or estate tax return has been filed to assess tax and        Code sections 2204 and 6905. We need it to ensure that 
demand payment of any deficiency. The executor                    you are complying with these laws and to allow us to 
representing a decedent’s estate or a fiduciary of a              figure and collect the right amount of tax. This  
decedent’s trust may request a discharge from personal            information is needed to determine eligibility for the  
liability for the decedent’s income, gift, and estate taxes.      requested discharge from personal liability. You are not  
Nine months, or 6 months in the case of a fiduciary’s             required to request discharge from personal liability;  
request, after the IRS’s receipt of the request for               however, if you do so you are required to provide the  
discharge or the earlier payment of any amount                    information requested on this form. Failure to provide the 
determined by the IRS to be owed, the executor or                 information may delay or prevent processing your  
fiduciary will be discharged from personal liability for any      request; providing false information may subject you to  
deficiency in such tax thereafter found to be due. In             penalties. Section 6109 requires you to provide the  
certain instances where the date for payment of the               requested taxpayer identification numbers. 
estate tax has been extended, the IRS may require a               You are not required to provide the information  
bond as a condition for discharge.                                requested on a form that is subject to the Paperwork  
An executor means the executor or administrator of a              Reduction Act unless the form displays a valid OMB  
decedent, who was appointed, qualified, and acting                control number. Books or records relating to a form or its 
within the United States.                                         instructions must be retained as long as their contents 
                                                                  may become material in the administration of any Internal 
When To File                                                      Revenue law. Generally, tax returns and return 
Do not file Form 5495 requesting a discharge from                 information are confidential, as required by section 6103. 
income or gift tax liability until after you file the tax returns However, section 6103 allows or requires the Internal 
listed on the front of this form. If you are requesting a         Revenue Service to disclose or give such information to 
discharge from personal liability for the estate tax, you         the Department of Justice for civil and criminal litigation; 
may attach this form to Form 706, United States Estate            to cities, states, the District of Columbia, and U.S. 
(and Generation-Skipping Transfer) Tax Return, or you             commonwealths and possessions to administer their tax 
may file this form any time during the 3-year period              laws; and to other countries under a tax treaty. We may 
following the date the Form 706 is filed. You must submit         also disclose this  information to federal and state 
a separate request for discharge from personal liability for      agencies to enforce federal nontax criminal laws, or to 
any tax returns filed after this Form 5495.                       federal law enforcement and intelligence agencies to 
                                                                  combat terrorism. 
Where To File                                                     The time needed to complete and file this form and  
Send your request to the Internal Revenue Service                 related schedules will vary depending on individual  
Center where you filed the returns listed on the front of         circumstances. The estimated average times are: 
this form. If you are requesting taxes reported on multiple       Recordkeeping  . . . . . . . . . . 5 hr., 30 min.    
returns filed at different Service Centers, you must mail 
separate Forms 5495 to each Service Center to receive a           Learning about the law   
discharge from liability for each type of tax. If an estate       or the form    . . . . . . . . . . . 1 hr., 30 min. 
tax return was filed, file Form 5495 for all taxes at the         Preparing the form     . . . . . . . . 4 hr., 27 min. 
address where the estate tax return was filed.                    Copying, assembling, and   
What To File                                                      sending the form to the IRS        . . . . . . . 48 min.  
This Form 5495 provides spaces for all information                If you have comments concerning the accuracy of 
required to process a request for discharge from                  these time estimates or suggestions for making this form 
personal liability under IRC section 2204 or 6905. Attach         simpler, we would be happy to hear from you. You can 
to your request the information and documentation                 write to the Internal Revenue Service, Tax Products 
requested on Form 5495. If you are submitting this                Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 
request with your estate tax return, you will not be              Constitution Ave. NW, IR-6526, Washington, DC 20224. 
required to provide an additional copy. If, however, this         Do not send the tax form to this address. Instead, see  
form is filed after Form 706, then a copy of pages 1–3 and        Where To File. 
Schedules A through I of Form 706 must be attached. If 
you are a fiduciary requesting discharge from personal 
liability under section 2204, check the “Other” box and 
include a copy of the trust instrument(s), a list of assets 
transferred from this decedent to the trust, and any other 
relevant  information. If you prefer to use your own 
format, your written request must list the same 
information as requested on this form and include the 
applicable attachments. 






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