Department of the Treasury
Internal Revenue Service

                                                DECLARATION

                          Executor's Commissions and Attorney's Fees

Estate of:
Date of Death:
I (We)                                                                            declare under
penalties of perjury that my (our) total commissions of $                    to administer this
estate and total attorney's fees of $                      have been agreed upon and have been or
will be paid as follows:

Name and Address            Social Security               Total Amount            Date Paid
of Payee                    Number of Payee               Paid or to be Paid      or to be Paid

Of the commissions or fees shown above, only $                         has been or will be claimed as
an income tax deduction. If the amounts or dates are changed, or if an election is made to claim
commissions or fees deducted on the estate tax return as an income tax deduction, the Internal Revenue
Service will be notified, and any resulting estate tax will be paid. The recipients of these commissions and
fees will report them for income tax purposes for the year received.

              (Signature of Executor or Administrator)                       (Date)

              (Signature of Executor or Administrator)                       (Date)

                        (Signature of Attorney)                              (Date)

                        (Signature of Attorney)                              (Date)

For Privacy Act Notice, see back of form.

          Cat. No. 41641V                                                    Form 4421 (Rev. 4-1987)

                                      Privacy Act Notice

Under the Privacy Act of 1974, we must tell you:         We ask for tax return information to carry out the In-
                                                         ternal Revenue laws-of the United States. We need it
Our legal right to ask for the information and           to figure and collect the right amount of tax.
whether the law says you must give it.
                                                         We may give the information to the Department of
What major purposes we have in asking for it, and        Justice and to other Federal agencies, as provided by
how it will be used.                                     law. We may also give it to cities, States, the District
                                                         of Columbia, and U.S. commonwealths or
What could happen if we do not receive it.               possessions to carry out their tax laws. And we may
                                                         give it to foreign governments because of tax treaties
                                                         they have with the United States.
The law covers: Tax returns and any papers
                                                         If you do not file a return, do not provide the infor-
filed with them. Any questions we need to ask            mation we ask for, or provide fraudulent information,
                                                         the law provides that you may be charged penalties
you so we can:                                           and, in certain cases, you may be subject to criminal
                                                         prosecution. We may also have to disallow the exemp-
Complete, correct, or process your return.               tions, exclusions, credits, deductions, or adjustments
Figure your tax.                                         shown on the tax return. This could make the tax
Collect tax, interest, or penalties.                     higher or delay any refund. Interest may also be
                                                         charged.
Our legal right to ask for information is Internal
Revenue Code sections 6001, 601 1, and 6012(a),          Please keep this notice with your records. It may help
and their regulations. They say that you must file a     you if we ask you for other information.
return or statement with us for any tax you are liable
for. Code section 6109 and its regulations say that      If you have questions about the rules for filing and
you must show your social security number on what        giving information, please call or visit any Internal
you file. This is so we know who you are, and can        Revenue Service office.
process your return and papers.
                                                         This is the only notice we must give you to explain the
You must fill in all parts of the tax form that apply to Privacy Act. However, we may give you other notices
you. But you do not have to check boxes for the          if we have to examine your return or collect any tax,
Presidential Election Campaign Fund.                     interest, or penalties.