965-D Transfer Agreement Under Section 965(i)(2)

965-D

Form
(December 2019)
Department of the Treasury
Internal Revenue Service

Part I

Transfer Agreement Under Section 965(i)(2)
▶

OMB No. 1545-0123

File in Duplicate
(see When and Where To File
in the separate instructions)

Go to www.irs.gov/Form965 for instructions and the latest information.

Transferor Information
Taxpayer identification number

Name of eligible section 965(i) transferor (see instructions for definition)
Address (number, street, room, suite, or P.O. box number)
City or town, state or province, country, and ZIP or foreign postal code

Part II

Transferee Information
Taxpayer identification number

Name of eligible section 965(i) transferee (see instructions for definition)
Address (number, street, room, suite, or P.O. box number)
City or town, state or province, country, and ZIP or foreign postal code

Part III

Identifying Information of the S Corporation (with respect to which the section 965(i) election was effective)
Taxpayer identification number

Name

Part IV

Triggering Event Leading to Transfer Agreement

1
2
3

Enter the date of the triggering event . . . . . . . . . . . . .
Was the transfer by reason of death of the transferor? . . . . . . .
Provide the portion, expressed as a percentage, of the transferor’s section
respect to the S corporation which is properly allocable to the portion
transferee . . . . . . . . . . . . . . . . . . . . . .

4

Provide a detailed description of the triggering event that led to the transfer agreement:

Part V
5

Yes

No

.

%

Report of Unpaid Section 965(i) Net Tax Liability or Portion Thereof Attributable to Transferred Stock

Enter the amount of the transferor’s unpaid section 965(i) net tax liability being assumed (see instructions)

Part VI
6
7
8

. . . . . . . . . . . ▶
. . . . . . . . . . . .
965(i) deferred net tax liability with
of stock being transferred to the
. . . . . . . . . . . .

$

Transferee’s Ability To Pay Remaining Liability

Is the transferee able to pay the section 965(i) net tax liability being assumed? . . . . . . . . . . .
Did the leverage ratio (see instructions) of the transferee, immediately after the triggering event, exceed 3:1? .
Provide any additional information pertaining to the transferee’s ability to pay (see instructions):

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 72588B

Yes
Yes

No
No

Form 965-D (12-2019)

Page 2

Form 965-D (12-2019)

Part VII

Terms of Agreement

By signing this transfer agreement, you agree to the following.
• This document constitutes an agreement by the transferee to assume the liability of the transferor for the unpaid portion of the
section 965(i) net tax liability or, in the case of a partial transfer, for the unpaid portion of the section 965(i) net tax liability
attributable to the transferred stock;
• The transferee agrees to comply with all the conditions and requirements of section 965(i) and Regulations section 1.965-7(c),
including the annual reporting requirement, as well as any other applicable requirements of the regulations under section 965;
• The transferor and any successor to the transferor will remain jointly and severally liable for the section 965(i) net tax liability being
assumed by the transferee;
• If the Commissioner requests additional information (for example, additional information regarding the ability of the transferee to
fully pay the section 965(i) net tax liability), the transferee will provide such information; and
• If the Commissioner determines, at the time of submission or such later date until the section 965(i) net tax liability has been fully
paid, that this transfer agreement contains a material misrepresentation or material omission, or if the transferee does not provide
the additional information requested by the Commissioner within a reasonable timeframe communicated by the Commissioner, the
Commissioner may reject the transfer agreement effective as of the date of the related triggering event or, in the alternative, on the
date the Commissioner determines that this transfer agreement includes a material misrepresentation or material omission.

Transferor
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, Parts I, III, IV, and V are true, correct and
complete. I certify that I have the authority to execute this transfer agreement for the eligible section 965(i) transferor reported in Part I.

▲

▲

Sign
Here

Signature

Date

Print name

Print title

Email address

Daytime phone

Transferee
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, Parts II, III, IV, V, and VI are true, correct and
complete. I certify that I have the authority to execute this transfer agreement for the eligible section 965(i) transferee reported in Part II.

Signature

▲

▲

Sign
Here

Date

Print name

Print title

Email address

Daytime phone
Form 965-D (12-2019)