Department of the Treasury – Internal Revenue Service
Form 13586-A                                        Announcement 2004-46
(May 2004)
                                           Settlement Initiative Declaration
Please complete the following information, sign and date this Declaration and return it along with the information requested in
Letter 3873. A self-addressed envelope has been provided for your convenience.

Section 1.                                 Taxpayer Data
1. Taxpayer name(s)                                                            2.  Taxpayer(s) identification
                                                                               number (EIN or SSN)

3. Address (Street, City, State, ZIP code)                                     4.  Daytime telephone number
                                                                               (                )
                                                                               5.  FAX number
                                                                               (                )
6. Total tax benefits claimed on return (See Form 13586, Section III, Line 6.)

7. Net out of pocket costs (See Form 13586, Section IV, Line 7.)

8. Elected method for handling "Net Out of Pocket" costs ("x" appropriate box.)

     a.  100% Long-Term Capital Loss                b.  50% Ordinary Loss

Section II.                                Taxpayer Attestation

                Under penalties of perjury, I declare that Form(s) 13586, the accompanying
                statements and documents provided are, to the best of my knowledge and belief,
                true, correct, and complete.

Signature of Taxpayer                                                          Date

Signature of Taxpayer                                                          Date

Catalog No. 38577S                      www.irs.gov                                       Form 13586-A (5-2004)