Form
1120-SF
(Rev. November 2018)
Department of the Treasury
Internal Revenue Service
U.S. Income Tax Return for Settlement Funds
(Under Section 468B)
Go to www.irs.gov/Form1120SF for instructions and the latest information.
For calendar year 20
OMB No. 1545-0123
Please Type or Print
Name of fund Employer identification number of fund (see instructions)
Number, street, and room or suite no. (If a P.O. box, see instructions.)
City or town, state or province, country, and ZIP or foreign postal code
Name and address of administrator (see instructions for definition)
Check applicable boxes: (1) Final return (2) Name change (3) Address change (4) Amended return
Part I Income and Deductions (see instructions)
Income
1 Taxable interest . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Capital gain net income (attach Schedule D (Form 1120)) . . . . . . . . . . . 3
4 Items of income or gain from a partnership interest . . . . . . . . . . . . . 4
5 Other income (attach statement) . . . . . . . . . . . . . . . . . . . 5
6 Gross income. Add lines 1 through 5 . . . . . . . . . . . . . . . . . 6
Deductions
7 Trustee/administrator fees . . . . . . . . . . . . . . . . . . . . . 7
8 Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Accounting and legal services (attach statement) . . . . . . . . . . . . . 9
10 Notification of claimants and claim processing expenses . . . . . . . . . . . 10
11 Other deductions (attach statement) . . . . . . . . . . . . . . . . . . 11
12 Net operating loss deduction . . . . . . . . . . . . . . . . . . . . 12
13 Total deductions. Add lines 7 through 12 . . . . . . . . . . . . . . . .
13
Part II Tax Computation (see instructions)
14 Modified gross income. Subtract line 13 from line 6 . . . . . . . . . . . . 14
15 Total tax. Multiply the amount on line 14 by 37% (0.37) . . . . . . . . . . .
15
16 Credits and payments:
a Overpayment from prior year allowed as
a credit . . . . . . . . . . . 16a
b Current year estimated tax payments . 16b
c Refund of overpaid estimated tax
applied for on Form 4466 . . . . . 16c
d Subtract line 16c from the total of lines 16a and 16b . . . . 16d
e Tax deposited with Form 7004 . . . . . . . . . . . 16e
f Total credits and payments (add lines 16d and 16e) . . . . . . . . . . . . . 16f
17 Estimated tax penalty. See instructions. Check if Form 2220 is attached . . . .
17
18 Tax due. If the total of lines 15 and 17 is more than line 16f, enter amount owed . . . 18
19 Overpayment. If line 16f is more than the total of lines 15 and 17, enter amount overpaid
19
20
Enter amount of line 19 you want: Credited to next year’s estimated tax
Refunded
. . . . . . . . . . . . . . . . . . . . . . . . . .
20
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature of fund administrator
Date
Title
May the IRS discuss this return
with the preparer shown below?
See instructions.
Yes No
Paid
Preparer
Use Only
Print/Type preparer’s name
Preparer’s signature Date
Check if
self-employed
PTIN
Firm’s name
Firm’s address
Firm’s EIN
Phone no.
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 14989I
Form
1120-SF (Rev. 11-2018)
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Form 1120-SF (Rev. 11-2018)
Page 2
Schedule L
Balance Sheets
(a) Beginning of year (b) End of year
Assets
1 Cash . . . . . . . . . . . . . . . . . . . . . 1
2 U.S. Government obligations . . . . . . . . . . . . . 2
3 State and local government obligations . . . . . . . . . . 3
4 Other investments (attach statement) . . . . . . . . . . . 4
5 Other assets (attach statement) . . . . . . . . . . . . 5
6 Total assets. Add lines 1 through 5 . . . . . . . . . . . 6
Liabilities and Fund Balance
7 Liabilities . . . . . . . . . . . . . . . . . . . . 7
8 Fund balance . . . . . . . . . . . . . . . . . . 8
9 Total. Add lines 7 and 8 . . . . . . . . . . . . . . . 9
Additional Information
Yes No
1
a Enter the amount of cash and the fair market value of property, valued at the date of the transfer,
transferred to the fund during the tax year . . . . . . . . . . . . . . . . . .
$
b For transfers of property included on line 1a, attach a copy of each qualified appraisal and the statements received
from a transferor under Regulations sections 1.468B-3(b) and 1.468B-3(e).
c Were amounts transferred to the fund during the tax year by a person other than a transferor? . . . . . .
2 Enter the amount of tax-exempt interest received or accrued during the tax year . . . . .
$
3a Were direct and indirect distributions made to claimants during the tax year? . . . . . . . . . . .
b If “Yes,” enter the amount of the total distributions . . . . . . . . . . . . . . .
$
4 a
Did the fund make any distributions (including deemed distributions) to a transferor or related party during the tax
year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b If “Yes,” enter the amount of the total distributions and attach a statement showing the name,
identifying number, and the amount of distributions to each transferor or related party . . .
$
5a Check the type of liability (or liabilities) for which the fund was established.
Tort
Breach of Contract
Violation of Law
CERCLA
Other
b
If “Other” is checked, enter the percent (by value) of the assets of the fund that are allocated to the
“Other” liability . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%
Attach a statement describing the type of liability (or liabilities).
6 If the fund was established by a court order, enter the Court Order Number under which the fund
was established . . . . . . . . . . . . . . . . . . . . . . . . . . .
Form 1120-SF (Rev. 11-2018)
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