Form 5495 - Request For Discharge From Personal Liability Under I.r. Code Sec. 2204 Or 6905
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25495
Request for Discharge From Personal Liability Under
OMB No. 1545-0432
For IRS Use Only
Form
Internal Revenue Code Section 2204 or 6905
(Rev. December 2008)
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
Income
Title
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 under
Here
which you were assessed a penalty, charged with, indicted for, or convicted of fraud.
Signature of requester
Date
Identifying number
5495
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Cat. No. 42571S
Form
(Rev. 12-2008)
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