Free Form 13586-A (5-2004) - Federal

Department of the Treasury ­ Internal Revenue Service

Form (May 2004)

13586-A

Announcement 2004-46 Settlement Initiative Declaration

Please complete the following information, sign and date this Declaration and return it along with the information requested in Letter 3873. A self-addressed envelope has been provided for your convenience.

Section 1.
1. Taxpayer name(s)

Taxpayer Data
2. Taxpayer(s) identification number (EIN or SSN)

3. Address (Street, City, State, ZIP code)

4. Daytime telephone number ( ) 5. FAX number ( )

6. Total tax benefits claimed on return (See Form 13586, Section III, Line 6.)

7. Net out of pocket costs (See Form 13586, Section IV, Line 7.)

8. Elected method for handling "Net Out of Pocket" costs ("x" appropriate box.) a. 100% Long-Term Capital Loss b. 50% Ordinary Loss

Section II.

Taxpayer Attestation
Under penalties of perjury, I declare that Form(s) 13586, the accompanying statements and documents provided are, to the best of my knowledge and belief, true, correct, and complete.

Signature of Taxpayer

Date

Signature of Taxpayer

Date

Catalog No. 38577S

www.irs.gov

Form 13586-A (5-2004)