Department of the Treasury — Internal Revenue Service
Form 13657
(March 2005)
Notice of Election by Corporation to Participate in
Announcement 2005-19 Settlement Initiative
The Service can decline to execute a closing agreement with any party that fails to provide all
information requested within this Form 13657.
NOTE:
Corporation InformationSection I.
Corporation name Corporation identification
number (EIN)
Address (Street, City, State, ZIP code)
Name and title of person to contact at corporation Daytime telephone number
FAX number
NoCorporation currently is in Appeals or Examination Yes (Please complete items 8 and 9.)
Name and address (Street, City, State, ZIP code) of Appeals Officer or Agent Daytime telephone number
NoCorporation has executed a Power of Attorney Yes (Please attach a copy.)
Identification number (EIN) for
Item 11 entries
Name of corporation(s) that received the services from the Executives named in Section III,
if different from corporation named in Item 1. (Attach additional sheets, if necessary.)
Did the Corporation file as part of a consolidated federal income tax
return for any taxable period affected by the terms of the settlement?
Yes (See Items 14 & 15 or Items 16 & 17,
whichever is applicable.)
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.
Name of authorized Corporate Representative
Corporation name
Title
DateBy (Signature of authorized Corporate Representative)
1. 2.
3.
4. 5.
6.
7.
8. 9.
10.
( )
( )
( )
11. 12.
13.
14.
No
Catalog No. 39566V Sheet 1 of 3
Form 13657 (3-2005)
www.irs.gov
15.
Name of the Corporation's parent that participated in the transaction (if the Corporation is a
subsidiary)
Employer identification number
(EIN) for Item 14 entry
Name of the Corporation's subsidiary that participated in the transaction (if the Corporation
is the parent)
16. 17. Employer identification number
(EIN) for Item 16 entry
click to sign
signature
click to edit
dd mmm yyyy
Election InformationSection II.
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):
the date(s) the stock options were transferred to the Related Person, or
December 31, 2004, or
December 31 of the year in which the Executive recognizes the compensation, or
Did the Corporation already claim a compensation deduction for any stock options or restricted stock that its Executives transferred
in Notice 2003-47 transactions?
NoYes (See instructions below.)
If "Yes," please attach a schedule listing the amounts and years of such deductions.
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.)
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.
Name and address (Street, City, State, ZIP code) of Executive Executive identification
number (SSN)
Name and address (Street, City, State, ZIP code) of Related Person to which the Executive
transferred the options or stock
Related Person identification
number (EIN)
Date(s) Executive transferred options or restricted stock to
Related Person
Date(s) such options were exercised or date(s) such
restricted stock vested
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?
NoYes (See instructions below.)
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.
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.
1.
2.
3.
1.
a.
b.
c.
d.
e.
the date(s) the options were exercised or the restricted stock vested, or
December 31 of the year determined under IRC section 3(c)(2) of Announcement 2005-19.
No
2.
3. 4.
5. 6.
7.
8.
Department of the Treasury – Internal Revenue Service
Catalog No. 39566V
Sheet 2 of 3
Form 13657 (3-2005)
www.irs.gov
Section III. Executive Information — continued
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?
NoYes
Is the Executive electing to participate in this settlement issue?
Unknown
9.
NoYes
10.
Department of the Treasury – Internal Revenue Service
Catalog No. 39566V
Sheet 3 of 3
Form 13657 (3-2005)
www.irs.gov
Instructions
Send your completed Form 13657 to:
Internal Revenue Service
ATTN: Announcement 2005-19
MC 4166 NWSAT
4050 Alpha Road
Farmers Branch, TX 75244
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.
1.
2.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome