Settlement Initiative Transactions Elected by Taxpayer
(For each box checked below, complete a separate Form 13750, Schedule A and attach it to your election)
10. Have you received a Statutory Notice of Deficiency
11. Has the TEFRA Partnership received a Notice of Final Partnership Administrative Adjustment
12. Do you have a Power of Attorney (If Yes, attach a copy to this election)
13. Have you filed an amended return(s) for any of the years in which you engaged in
this transaction(s) (If Yes, attach a copy or copies to this election)
Department of the Treasury — Internal Revenue Service
Election to Participate in Announcement 2005-80
Settlement Initiative
You must provide all the information required under this Election by January 23, 2006 (or as otherwise
stipulated in subsequent requests from the Service for additional information) to be eligible for the settlement.
Taxpayer DataSection I
I elect to participate in the settlement initiative as described in Announcement 2005-80 and as contained in Internal
Revenue Bulletin 2005-46 dated November 14, 2005.
1. Taxpayer name(s) (Include name of spouse if joint return) 2. Taxpayer(s) Identification
Number (EIN or SSN)
6. Are you currently under examination or in Appeals 7. Are/were you (or your spouse) a partner in a TEFRA partnership
that was a party to the arrangement(s) identified in Section II
Yes
No (Please provide copies of all relevant tax
returns with your election submission)
Yes (Please complete items 8a and 8b)
No
No
NoYes
No
Section II
Catalog No. 47521K
Form 13750 (10-2005)
www.irs.gov
Note
3. Address (Street, City, State, ZIP code) 4. Telephone number
( )
Yes (Complete items 9a & 9b and Section III)
8a. Name and address (Street, City, State, ZIP Code) of
IRS contact for your current examination or Appeals
matter (If applicable)
9a. Name and address (Street, City, State, ZIP Code) of
IRS contact for the TEFRA Partnership examination
or Appeals matter (If applicable)
Notice 2002-21 (20% penalty)
Notice 2001-16 (20% penalty)
Notice 2003-55 (10% or 20% penalty)
Notice 2003-54 (10% penalty)
Notice 2003-81 (10% penalty)
Notice 99-59 (10% penalty)
Revenue Ruling 2004-98 (5% penalty)
Revenue Ruling 2004-20 & 2004-21 (5% penalty)
Notice 2004-8 (5% penalty)
Revenue Ruling 2004-4 (5% penalty)
Yes
NoYes
Notice 2003-77 (5% penalty)
Notice 2003-24 (5% penalty)
Revenue Ruling 2003-6 (5% penalty)
Revenue Ruling 2002-3 & 2002-80 (5% penalty)
Notice 2000-60 (5% penalty)
Revenue Ruling 2000-12 (5% penalty)
Notice 95-34 (5% penalty)
Treasury Regulation § 1.643(a)-8 (5% penalty)
Notice 2004-41 (5% penalty)
Notice 2004-7 (5% penalty
Management S Corporation ESOP Transactions (5% penalty)
OMB No. 1545-1970
Form 13750
(October 2005)
5. FAX number
( )
8b. Telephone number of IRS contact
( )
9b. Telephone number of IRS TEFRA contact
( )
2. I obtained a written tax opinion by an independent tax advisor (If box is checked, please complete a separate
Form 13750, Schedule B for each issue to which the opinion applies and attach it to your election).
1. I filed a disclosure under Announcement 2002-2
Under penalties of perjury, I declare that I have examined these statements, accompanying
schedules, and attachments, and to the best of my knowledge and belief, they are true, correct,
and complete.
Penalties
Taxpayer
Attestation
Instructions
Section IV
Signature of Taxpayer Date
I may qualify for a 0% penalty under IRC § 6662 for the following reasons (Check all that apply)
Ineligible Taxpayer Special Request for InclusionSection III
I am a promoter as outlined in Section 2, paragraph 1 of the Announcement
I am ineligible to participate in the Announcement 2005-80 settlement initiative because – (Check all that apply)
I am a person related to a promoter as outlined in Section 2, paragraph 2 of the Announcement
I am a TEFRA partner or promoter as outlined in Section 2, paragraph 3 of the Announcement
Despite my ineligibility, I request that the Service permit settlement under this initiative for the following reason(s)
Send your completed Form 13750 and all required
attachments to:
If you are under examination (or in Appeals) or if any
TEFRA partnership in which you are a partner is under
examination (or in Appeals), please send a copy of this
Election to the IRS examiner (or IRS Appeals Officer).
Privacy Act Statement
Page 2 of 4
Signature of Taxpayer Date
Catalog No. 47521K
Form 13750 (10-2005)
www.irs.gov
The Privacy Act of 1974 says that when we ask you for information, we must first tell you our legal right to ask for the information, why we are asking for it, and how it will be
used. We must also tell you what could happen if you do not provide it and whether or not you must respond under the law.
This notice applies to tax returns and any papers filed with them. It also applies to any questions we need to ask you so we can complete, correct, or process your return;
figure your tax; and collect tax, interest, or penalties.
Our legal right to ask for information is found in Internal Revenue Code sections 6001, 6011, and 6012(a) and their regulations. They say that you must file a return or
statement with us for any tax you are liable for. Your response is mandatory under these sections.
Code section 6109 and its regulations say that you must show your social security number, employer identification number or individual taxpayer identification number on
what you file. Section 6109 also requires return preparers to provide their identifying numbers on the return. You must also fill in all parts of the tax form that apply to you. This
is so we know who you are and can process your return and papers.
We ask for tax return information to carry out the U.S. tax laws. We need it to figure and collect the right amount of tax. We may give the information to the Department of
Justice and to other federal agencies, as provided by law. We may also give it to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out
their tax laws. And we may give it to certain foreign governments under tax treaties they have with the United States. We may also disclose this information to federal and
state agencies to enforce federal non-tax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
If you do not file a return, do not give us the information we ask for, or provide fraudulent information, the law says that we may have to charge you penalties and, in certain
cases, subject you to criminal prosecution. We may also have to disallow the exemptions, exclusions, credits, deductions, or adjustments shown on your tax return. This could
make your tax higher or delay any refund. Interest may also be charged.
INTERNAL REVENUE SERVICE
Attn: Announcement 2005-80
MS1505
24000 Avila Road
Laguna Niguel, CA 92677
For additional information, please refer to the IRS website
at www.irs.gov. A link to Announcement 2005-80 will be
displayed on the main page.
click to sign
signature
click to edit
click to sign
signature
click to edit
(If additional space is required, please include information on a separate attachment to this schedule)
2. Enter the applicable Tax Shelter Registration (or Material Advisor) number (if registered)
6. Are your tax matters with respect to this elected transaction currently in litigation
7. Has the Service informed you it has designated (or is considering designation
of) your transaction for litigation
8. Are you currently a party to any bankruptcy proceeding
Schedule A
Transaction Costs paid to
(If additional space is required, please include information on a separate attachment to this schedule)
Details of Settlement Initiative Transactions Elected by Taxpayer
(A separate Schedule A must by submitted for each transaction checked in Section II of Form 13750)
Indicate the notice, ruling or other transaction description for the box checked in Section II to which this Schedule A applies
1. Please provide a detailed description of your particular transaction, including a description of the relevant tax benefits
(Including, but not limited to income deferrals, deductions, credits, exclusions, and basis adjustments)
(If additional space is required, please include information on a separate attachment to this schedule)
3. Transaction details
4. Transaction costs (i.e. fees and other amounts paid to promoters, attorneys, accountants, appraisers, or others to plan and carry
out the transaction)
5. Other parties to the transaction (including but not limited to the names of employees who are affected by an employer's transactions)
(If additional space is required, please include information on a separate attachment to this schedule)
Yes No
NoYes
NoYes
Page 3 of 4
Tax Years
Involved
Name Business Address Relationship
Amount(s)
Paid
Catalog No. 47521K
Form 13750 (10-2005)
www.irs.gov
Tax Years
Involved
Type of Tax
(income, excise,
employment, etc.)
Amount of Tax
at Issue
Amount of Tax Benefits
Claimed on Tax Return
Line Item Where
Benefit Claimed
Date Tax
Return Filed
Party Name EIN/SSN Address Daytime Phone Number
11. Were the advisor's fees contingent upon the intended tax benefits
(If No, please describe the fee arrangement in item 13)
12. To your knowledge, did the advisor issue similar tax opinions regarding the
transaction to other taxpayers
1. Did you receive a written tax opinion. If Yes, include a copy with your election
(Note: If you received a written opinion, failure to include a copy will disqualify you
from consideration for relief under this section)
2. Did you receive the written tax opinion before filing the affected tax return(s)
3. Did you implement the transaction as described in the opinion. If No, complete item 4
4. Describe how you implemented the transaction differently from the description in the opinion received
5. Was an independent written appraisal obtained to support the written tax opinion
(If Yes, include a copy with your election)
Taxpayer – Tax Advisor Relationship Matters
6. Was a tax advisor recommended by a promoter of the transaction
7. Who recommended the tax advisor
8. Did you have a retainer or other agreement with the tax advisor setting forth
the terms of engagement. (If Yes, include a copy with your election.)
9. Who paid the advisor's fees
10. How much were the advisor's fees (by year)
Indicate the notice, ruling or other transaction description for the box checked in Section II to which this Schedule B applies
Tax Opinion Matters
Yes No
NoYes
Yes No
Yes No
Yes No
NoYes
I did
Yes
No
Don't know Yes
No
13. Additional information
Page 4 of 4
Paperwork Reduction Act Notice: We ask for the information on this form to carry out the internal revenue laws of the United States. We need it to
insure that taxpayers are complying with these laws and to allow us to figure and collect the right amount of tax.
You are required to give us the information if you are applying for a reward.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays
a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in
the administration of any internal revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.
The time needed to complete this form will vary depending on individual circumstances. The estimated average time is 300 minutes. If you have
comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can
email us at *taxforms@irs.gov (please type "Forms Comment" on the subject line) or write to the Internal Revenue Service, Tax Forms Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406, Washington, DC 20224.
Schedule B
Details of Tax Advice
(A separate Schedule B must by submitted for each transaction checked in Section II of Form 13750, where a
written tax opinion for that transaction was obtained, as indicated in Section IV, Item 2 of Form 13750)
Catalog No. 47521K
Form 13750 (10-2005)
www.irs.gov
Another individual (Please provide individuals name)
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