Free Form 13657 (3-2005) - Federal

Department of the Treasury -- Internal Revenue Service

Form 13657 (March 2005)

Notice of Election by Corporation 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 13657. Section I.
1. Corporation name

Corporation Information
2. Corporation identification number (EIN)

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

4. Name and title of person to contact at corporation

5. Daytime telephone number ( ) 6. FAX number ( )

7. Corporation currently is in Appeals or Examination

Yes (Please complete items 8 and 9.)

No

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

9. Daytime telephone number ( )

10. Corporation has executed a Power of Attorney

Yes (Please attach a copy.)

No

11. Name of corporation(s) that received the services from the Executives named in Section III, 12. Identification number (EIN) for if different from corporation named in Item 1. (Attach additional sheets, if necessary.) Item 11 entries

13. Did the Corporation file as part of a consolidated federal income tax return for any taxable period affected by the terms of the settlement?
subsidiary)

Yes (See Items 14 & 15 or Items 16 & 17,
whichever is applicable.)

No

14. Name of the Corporation's parent that participated in the transaction (if the Corporation is a

15. Employer identification number (EIN) for Item 14 entry 17. Employer identification number (EIN) for Item 16 entry

16. Name of the Corporation's subsidiary that participated in the transaction (if the Corporation
is the parent)

Corporation Attestation
The following Corporation elects 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. The Corporation is submitting with this election the information and documents requested. Under penalties of perjury, I declare that I have examined this Form 13657 and to the best of my knowledge and belief, it is true, correct and complete.
Corporation name Name of authorized Corporate Representative

Title

By (Signature of authorized Corporate Representative) Catalog No. 39566V Sheet 1 of 3
www.irs.gov

Date Form 13657 (3-2005)

Section II.

Election Information

1. Pursuant to section 3(b)(1) and section 3(c)(2) of Announcement 2005-19, the Corporation elects to claim the allowable compensation deduction in its taxable year that includes ("X" only one): a. the date(s) the stock options were transferred to the Related Person, or b. the date(s) the options were exercised or the restricted stock vested, or c. December 31, 2004, or d. December 31 of the year in which the Executive recognizes the compensation, or e. December 31 of the year determined under IRC section 3(c)(2) of Announcement 2005-19. 2. Did the Corporation already claim a compensation deduction for any stock options or restricted stock that its Executives transferred in Notice 2003-47 transactions? Yes (See instructions below.) No

If "Yes," please attach a schedule listing the amounts and years of such deductions. 3. Did the Corporation already claim any deductions for transaction costs (i.e., fees paid to promoters, attorneys, accountants, appraisers, or others) concerning Notice 2003-47 transactions? Yes (See instructions below.) No

If "Yes", please attach a schedule listing the amounts and years of such deductions. If the Corporation wishes to claim deductions for such costs that have not been previously deducted, also attach a schedule\ listing the amounts and years of such fees and attach documents substantiating payment.

Section III.

Executive Information

For each Executive (Officer, Director, employee) who participated in a Notice 2003-47 transaction using either stock options granted or restricted stock issued by the Corporation, please provide the following information. If you need additional space for your answers, please attach additional sheets and identify the continued answers by item number.
1. Name and address (Street, City, State, ZIP code) of Executive 2. Executive identification number (SSN)

3. Name and address (Street, City, State, ZIP code) of Related Person to which the Executive transferred the options or stock

4. Related Person identification number (EIN)

5. Date(s) Executive transferred options or restricted stock to Related Person

6. Date(s) such options were exercised or date(s) such restricted stock vested

7. Was a Form 1099 or Form W-2 issued to the Executive upon the Executive's transfer of the options or the restricted stock to the Related Person? Yes (See instructions below.) No

If "Yes," please attach copies of the form and specify the amount representing the option or restricted stock value included on the Form 1099 or Form W-2. 8. Was a Form 1099 or Form W-2 issued to the Executive upon the exercise of the options or the vesting of the restricted stock? Yes (See instructions below.) No

If "Yes," please attach copies of the form and specify the amount representing the option or restricted stock value included on the Form 1099 or Form W-2. Form 13657 (3-2005)
Catalog No. 39566V

Sheet 2 of 3

www.irs.gov

Department of the Treasury ­ Internal Revenue Service

Section III. Executive Information -- continued
9. Was any portion of the stock options or restricted stock awarded to the Executive in connection with the Executive's performance of services for a subsidiary or affiliate of the Corporation? Yes No

10. Is the Executive electing to participate in this settlement issue? Yes No Unknown

Instructions
1. Send your completed Form 13657 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 13657 (3-2005)
Catalog No. 39566V

Sheet 3 of 3

www.irs.gov

Department of the Treasury ­ Internal Revenue Service