Free Form 13656 (3-2005) - Federal

Form 13656 (March 2005)

Department of the Treasury -- Internal Revenue Service

Notice of Election by Executive and Related Person to Participate in Announcement 2005-19 Settlement Initiative

NOTE: The Service can decline to execute a closing agreement with any party that fails to provide all information requested within this Form 13656. Section I. Executive Information
2. Social security number (SSN)
(Executive) (Spouse)

1. Executive name (and name of spouse, if joint return)

­ ­

­ ­

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

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

6. Executive currently is in Appeals or Examination Yes (Please complete items 8 and 9.) No

7. Executive has executed a Power of Attorney Yes (Please attach a copy.) No 9. Daytime telephone number ( )

8. Name and address (Street, City, State, ZIP code) of Appeals Officer or Agent

Executive Attestation

I elect to participate in the settlement initiative as described in Announcement 2005-19 and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005. I am submitting with this election the information and documents requested. Under penalties of perjury, I declare that I have examined this Form 13656 and to the best of my knowledge and belief, it is true, correct and complete.
Signature of Executive Date

Section II.

Related Person Information
2. Related Person identification number (EIN)

1. Name of Related Person to which stock options or restricted stock were transferred

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

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

6. Related Person has executed a Power of Attorney

Yes (Please attach a copy.)

No

Catalog No. 39565K

Sheet 1 of 4

www.irs.gov

Form 13656 (3-2005)

Section II. Related Person Information -- continued
Related Person Attestation All partners/members of the Related Person elect to participate in the settlement initiative as described in Announcement 2005-19 and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005. Under penalties of perjury, I declare that I have examined this Form 13656 and to the best of my knowledge and belief, it is true, correct and complete.
1. 2. 3. 4. 5. 6. 7. 8. Name (Please print.) Name (Please print.) Name (Please print.) Name (Please print.) Name (Please print.) Name (Please print.) Name (Please print.) Name (Please print.) Signature Signature Signature Signature Signature Signature Signature Signature Date Date Date Date Date Date Date Date

Section III.

Corporation Information
2. Corporation identification number (EIN)

1. Name of corporation that issued the stock options or restricted stock

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

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

6. Is the corporation electing to participate in this settlement initiative?
corporation named in Section III, Item 1)

Yes

No

Unknown

7. Name of corporation that received the services from the Executive (if different from the

8. Corporation identification number (EIN)

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

10. Daytime telephone number ( ) 11. FAX number ( )

Form 13656 (3-2005)
Catalog No. 39565K

Sheet 2 of 4

www.irs.gov

Department of the Treasury ­ Internal Revenue Service

Section IV.

Information and Documentation Required to Process Election by Executive and Related Person

Answer the following questions and provide the listed documentation. If you need additional space for your answers, please attach additional sheets and identify the continued answers by item number. "Provide documentation" means "Attach copies of documents that verify your responses."
1. What did the Related Person transfer to the Executive in exchange for the stock options or restricted stock the Executive transferred to the Related Person? On what date(s) did the transfer or sale occur? Provide documentation (including copies of any promissory notes and appraisal reports).

2. On what date(s) did the Related Person exercise stock options it received from the Executive? Does the Related Person still hold Yes No (Or, on what date did the restricted stock vest?) options it has not exercised? What was the fair market value of the stock on the exercise date or the date of vesting? Provide documentation.

3. Has the Related Person paid any amounts (including interest) to the Executive? Yes (Provide documentation of all payments.) No

4. Did the Related Person or the Executive pay any transaction costs (including promoter, accounting, appraisal, and legal fees)? Yes (Provide documentation of all payments.) No

5. Has the Related Person sold all the stock it acquired through this transaction (including stock acquired by exercising options)? Yes (See below.) No

Note: For any stock sold, provide a schedule listing the number of shares sold, the date of sale, the sales price, and the claimed basis at the date of sale. Provide documentation.

6. Provide copies of all promotional packages, legal opinions, or engagement letters obtained by the Executive or the Related Person (or any person acting on their behalf) pertaining to this transaction. 7. Provide the name, address, and telephone number of the entity and person(s) that sold or promoted the sale of the transaction described in Announcement 2005-19 to the Executive or the Related Person.

8. Provide a computation of any tax and penalty due from the Executive under the terms of Announcement 2005-19.

9. Provide a computation of the Related Person's basis in stock still held pursuant to Announcement 2005-19.

Form 13656 (3-2005)
Catalog No. 39565K

Sheet 3 of 4

www.irs.gov

Department of the Treasury ­ Internal Revenue Service

Section IV. -- continued

Information and Documentation Required to Process Election by Executive and Related Person

10. Provide a computation of any change in the tax liability of the Related Person as a result of this Election.

11. Is the Executive or Related Person currently in tax litigation with the government? Yes (Provide a copy of the complaint
or the Tax Court petition.)

No

12. Provide copies of all federal tax returns filed by the Related Person and the Executive from the date the options or restricted stock was transferred to the Related Person to the present. 14. Has the Executive filed a Qualified Amended Return (as defined by Treas. Reg. §1.6664-2(c)(3)) pertaining to the transaction?

13. Provide a schedule listing the names, addresses, and SSNs of the following: a. All partners or members of the Related Person and b. The spouses of partners or other members of passthrough entities who filed joint returns for any taxable period affected by the terms of the settlement. 15. Has the Executive filed a disclosure statement pertaining to the transaction pursuant to Announcement 2002-2? Yes (Provide a copy.) No

Yes (Provide a copy.)

No

16. Has the Executive or the Related Person received a Form W-2 or Form 1099 pertaining to the transaction? Yes (Provide a copy of all forms.) No

Instructions
1. Send your completed Form 13656 to:
Internal Revenue Service ATTN: Announcement 2005-19 MC 4166 NWSAT 4050 Alpha Road Farmers Branch, TX 75244

2. If you are under examination or in Appeals, please provide a copy of this Notice of Election to the examining revenue agent or the Appeals Officer.

Form 13656 (3-2005)
Catalog No. 39565K

Sheet 4 of 4

www.irs.gov

Department of the Treasury ­ Internal Revenue Service