Ex. U Statement of Annual Income -- Individual
Applicable year: _______
To Chief, Special Procedures Function
_____________________________________Kind of Tax Compromised
_______________________________From Name and address of taxpayer(s) Years or Periods Compromised
_______________________________
_____________________________________Social Security Number(s) and Employer Identification Number
_______________________________
1. Adjusted gross income from line ___ of Form 1040 ("AGI") $______ 2. Add: (a) Nontaxable income $______ (b) Fair market value of gifts, bequests, etc. ______ (c) Losses from sale or exchange of property ______ (d) Pro rata share of partnership and S corp. losses from sale or exchange of property ______ (e) Deductions taken for IRA or contribution to self-employment retirement plan ______ (f) Deduction taken for NOL carry back/forward ______ (g) Pro rata share of undistributed income ______ (h) Other (attach explanation) ______ Total additions and excluded deductions: ______ ______ 3. Sum of items 1 and 2 above: ______ 4. Less: (a) Installment payments made under settlement during applicable year ______ (b) Income taxes reported and paid with respect to applicable year:
(1) Federal
(2) State
(3) Local$______
$______
$______(If individual taxpayer files joint return with non-liable spouse, attach computation of subtractable portion of income taxes, and well as hypothetical separate tax returns or equivalent information, and specify percentage here: %. See paragraphs 2 and 5 of collateral agreement.)
Total subtractable income taxes
______ Total substractions: ______ ______ 5. Annual Income (item 3 minus item 4): $______ 6. Computation of payment due under the collateral agreement: (a) Nothing for the first $______ of annual income. (b) ____% of $______ (annual income from $______ to $______) = $______ (c) ____% of $______ (annual income from $______ to $______) = $______ (d) ____% of $______ (annual income from $______ to $______) = $______ (e) ____% of $______ (annual income from $______ to $______) = $______ (f) ____% of $______ (annual income in excess of $______) = $______ TOTAL PAYMENT DUE UNDER COLLATERAL AGREEMENT: $______ 7. Interest due on above amount (see paragraph 5 of the collateral agreement) $______ 8. Total amount due under the collateral agreement with respect to the applicable tax year. (Pay in full herewith.) $______
This statement of annual income for the applicable tax year indicated above is filed as required by the terms of a collateral agreement executed as part of a settlement respecting the tax liability for the periods shown above. I am attaching copies of my income tax returns (federal, state, and local if applicable), including any Forms W-2 and schedules, for the applicable tax year.
Under penalty of perjury, I declare that I have examined this statement and that it is true, correct, and complete.
_______________________
Your Signature_______________________
Spouse's Signature if Joint___________
Date
Statement of Annual Income -- Corporate
Applicable year: _____
To Chief, Special Procedures Function
_____________________________________Kind of Tax Compromised
_______________________________From Name and Address of Corporation Years or Periods Compromised
_______________________________
_____________________________________Employer Identification No.
_______________________________
1. Adjusted gross income from line ___ of Form 1120 ("TI") $______ 2. Add: (a) Tax-exempt, excludable, or other nontaxable income $______ (b) Special deductions taken (dividends received, certain dividends paid, amortization of start-up costs, etc., Code Sections 241 through 250) ______ (c) Losses from sale or exchange of property ______ (d) Deduction taken for NOL carry back/forward ______ (e) Pro rata share of undistributed income (over $10,000) of any partially owned subsidiaries not included on consolidated return ______ (f) Other (attach explanation) ______ Total additions and excluded deductions: ______ ______ 3. Sum of items 1 and 2 above: ______ 4. Less: (a) Installment payments made under settlement during applicable year ______ (b) Income taxes reported and paid with respect to applicable year:
(1) Federal
(2) State
(3) Local$______
$______
$______Total subtractable income taxes
______ Total substractions: ______ ______ 5. Annual Income (item 3 minus item 4): $______ 6. Computation of payment due under the collateral agreement: (a) Nothing for the first $______ of annual income. (b) ____% of $______ (annual income from $______ to $______) = $______ (c) ____% of $______ (annual income from $______ to $______) = $______ (d) ____% of $______ (annual income from $______ to $______) = $______ (e) ____% of $______ (annual income from $______ to $______) = $______ (f) ____% of $______ (annual income in excess of $______) = $______ TOTAL PAYMENT DUE UNDER COLLATERAL AGREEMENT: $______ 7. Interest due on above amount (see paragraph 4 of the collateral agreement) $______ 8. Total amount due under the collateral agreement with respect to the applicable tax year. (Pay in full herewith.) $______
This statement of annual income for the applicable tax year indicated above is filed as required by the terms of a collateral agreement executed as part of a settlement respecting the tax liability for the periods shown above. I am attaching a copy of my income tax returns (federal, state, and local if applicable), including any schedules, for the applicable tax year.
Under penalty of perjury, I declare that I have examined this statement and that it is true, correct, and complete.
_______________________
Signature of President or Other Principal Officer_______________________
Title___________
Date
Title Page || Contents || Section I || Section II || Section III
Section IV || Section V || Section VI || Appendices
Table of Cases and Authorities
