U.S. Income Tax Return for Settlement Funds  
Form 1120-SF
(Rev. December 2016)                                                                              (Under Section 468B)                                                                             OMB No. 1545-0123
                                                                    ▶
Department of the Treasury                                             Information about Form 1120-SF and its separate instructions is at www.irs.gov/form1120sf.
Internal Revenue Service                                                                               For calendar year 20
                                                   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) 
                    Please Type or Print
                                                   Check applicable boxes:   (1)          Final return                 (2)     Name change   (3)   Address change                             (4)        Amended return
Part I                                                  Income and Deductions (see instructions) 
                                                   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
                                        Income
                                                   5    Other income (attach schedule)  .       . .    .               .   . . . . . . .   .  .  . . .     . .                             5
                                                   6    Gross income. Add lines 1 through 5  .         .               .   . . . . . . .   .  .  . . .     . .                             6
                                                   7    Trustee/administrator fees  .       . . . .    .               .   . . . . . . .   .  .  . . .     . .                             7
                                                   8    Taxes  . .  . .    . .          . . . . . .    .               .   . . . . . . .   .  .  . . .     . .                             8
                                                   9    Accounting and legal services (attach schedule)  .                   . . . . . .   .  .  . . .     . .                             9
                                                   10   Notification of claimants and claim processing expenses  .                 . . .   .  .  . . .     . .                             10
                                                   11   Other deductions (attach schedule)  .     .    .               .   . . . . . . .   .  .  . . .     . .                             11
                                        Deductions 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 39.6% (0.396)   .               . .   .  .  . . .     . .                             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
                                                      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.
Sign                                                  ▲                                                                            ▲                                                          May  the  IRS  discuss  this  return 
                                                                                                                                                                                              with the preparer shown below? 
Here                                                                                                                                                                                          See instructions.      Yes No
                                                        Signature of fund administrator                                Date          Title
                                                        Print/Type preparer’s name                     Preparer’s signature                          Date                                                        PTIN
Paid                                                                                                                                                                                          Check          if  
                                                                                                                                                                                              self-employed 
Preparer                                                                                                                                                                                                ▶
                                                        Firm’s name     ▶                                                                                                                     Firm’s EIN 
                                                        Firm’s address 
Use Only                                                                 ▶                                                                                                                    Phone no. 
For Paperwork Reduction Act Notice, see separate instructions.                                                                             Cat. No. 14989I                                    Form 1120-SF (Rev. 12-2016) 

Form 1120-SF (Rev. 12-2016)                                                                                                        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 schedule)  .    . .  . .     . . . .       . .   4

5  Other assets (attach schedule)  .    . .  . .  . .     . . . .       . .   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

1a 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  . . . .       . . . .    . .  . . . . . $

4a 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. 12-2016)