Schedule C-1 Closely-Held Corporate Stock Information Report {REV-1505}

1.Name of Corporation State of Incorporation Address Date of Incorporation City State ZIP CodeTotal Number of Shareholders 2.Federal Employer ID002Number Business Reporting Year 3.Type of Business Product/Service 4.Provide all rights and restrictions pretaining to each class of stock.5.Was the decedent employed by the corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .002Yes 002No If yes, Position Annual Salary $ Time Devoted to Business6.Was the corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .002Yes 002No If yes, provide amount of indebtedness $If yes, Cash Surrender Value $Net proceeds payable $ Owner of the policy8.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? 002Yes 002NoIf yes, 002Transfer 002SaleNumber of Shares Transferee or Purchaser Consideration $ DateAttach a separate sheet for additional transfers and/or sales.9.Was there a written shareholder003s agreement in effect at the time of the decedent003s death? . . . .002Yes 002NoIf yes, provide a copy of the agreement.10.Was the decedent003s stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .002Yes 002No(If more space is needed, insert additional sheets of the same size.) THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULEA.Detailed calculations used in the valuation of the decedent003s 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 havebeen secured, attach copies.D.List of principal stockholders at the date of death, number of shares held and their relationships to the decedent.STOCKCommonPreferred$$ PAR VALUE TOTAL NUMBER OFSHARES OUTSTANDING TYPEVoting/Non-Voting NUMBER OF SHARESOWNED BY THE DECEDENT VALUE OF THE DECEDENT220S STOCK REV-1505 EX+ (11-11) INHERITANCE TAX RETURNRESIDENT DECEDENT American LegalNet, Inc. www.FormsWorkFlow.com