PDF document

- 1 -

                                            Department of the Treasury — Internal Revenue Service
Form 13750                    Election to Participate in Announcement 2005-80                                     OMB No. 1545-1970
(October 2005)
                                                    Settlement Initiative
             You must provide all the information required under this Election by January 23, 2006 (or as otherwise
Note
             stipulated in subsequent requests from the Service for additional information) to be eligible for the settlement.
Section I                                                     Taxpayer Data
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)

3. Address (Street, City, State, ZIP code)                                                        4. Telephone number
                                                                                                     (           )
                                                                                                  5. FAX number
                                                                                                     (           )
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 (Please complete items 8a and 8b)
                                                                               Yes (Complete items 9a & 9b and Section III)
      No (Please provide copies of all relevant tax
             returns with your election submission)                            No
8a. Name and address (Street, City, State, ZIP Code) of             9a. Name and address (Street, City, State, ZIP Code) of
      IRS contact for your current examination or Appeals                 IRS contact for the TEFRA Partnership examination
      matter (If applicable)                                              or Appeals matter (If applicable)

8b. Telephone number of IRS contact                                 9b. Telephone number of IRS TEFRA contact
(           )                                                               (           )
10. Have you received a Statutory Notice of Deficiency                                                            Yes      No

11. Has the TEFRA Partnership received a Notice of Final Partnership Administrative Adjustment                    Yes      No

12. Do you have a Power of Attorney  (If Yes, attach a copy to this election)                                     Yes      No

13. Have you filed an amended return(s) for any of the years in which you engaged in
                                                                                                                  Yes      No
      this transaction(s) (If Yes, attach a copy or copies to this election)
                                   Settlement Initiative Transactions Elected by Taxpayer
Section II
              (For each box checked below, complete a separate Form 13750, Schedule A and attach it to your election)

      Notice 2002-21 (20% penalty)                                          Notice 2003-77 (5% penalty)
      Notice 2001-16 (20% penalty)                                          Notice 2003-24 (5% penalty)
      Notice 2003-55 (10% or 20% penalty)                                   Revenue Ruling 2003-6 (5% penalty)
      Notice 2003-54 (10% penalty)                                          Revenue Ruling 2002-3 & 2002-80 (5% penalty)
      Notice 2003-81 (10% penalty)                                          Notice 2000-60 (5% penalty)
      Notice 99-59 (10% penalty)                                            Revenue Ruling 2000-12 (5% penalty)
      Revenue Ruling 2004-98 (5% penalty)                                   Notice 95-34 (5% penalty)
      Revenue Ruling 2004-20 & 2004-21 (5% penalty)                         Treasury Regulation § 1.643(a)-8 (5% penalty)
      Notice 2004-8 (5% penalty)                                            Notice 2004-41 (5% penalty)
      Revenue Ruling 2004-4 (5% penalty)                                    Notice 2004-7 (5% penalty
                                                                            Management S Corporation ESOP Transactions (5% penalty)

Catalog No. 47521K                                                 www.irs.gov                                    Form 13750 (10-2005)

- 2 -

Page 2 of 4
Section III Ineligible Taxpayer Special Request for Inclusion
I am ineligible to participate in the Announcement 2005-80 settlement initiative because – (Check all that apply)
I am a promoter as outlined in Section 2, paragraph 1 of the Announcement
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)

Section IV Penalties
I may qualify for a 0% penalty under IRC § 6662 for the following reasons (Check all that apply)
1. I filed a disclosure under Announcement 2002-2

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).
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.
Signature of Taxpayer Date
Taxpayer
Attestation
Signature of Taxpayer Date

Instructions
• Send your completed Form 13750 and all required • If you are under examination (or in Appeals) or if any
attachments to: TEFRA partnership in which you are a partner is under
examination (or in Appeals), please send a copy of this
INTERNAL REVENUE SERVICE Election to the IRS examiner (or IRS Appeals Officer).
Attn: Announcement 2005-80
MS1505
24000 Avila Road • For additional information, please refer to the IRS website
Laguna Niguel, CA 92677 at www.irs.gov. A link to Announcement 2005-80 will be
displayed on the main page.
Privacy Act Statement
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.
Catalog No. 47521K www.irs.gov Form 13750 (10-2005)

- 3 -

                                                                                                                               Page 3 of 4
                                       Details of Settlement Initiative Transactions Elected by Taxpayer
    Schedule A
                        (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)
2. Enter the applicable Tax Shelter Registration (or Material Advisor) number (if registered)
3. Transaction details
                   Type of Tax
Tax Years    (income, excise,          Amount of Tax      Amount of Tax Benefits         Line Item Where                 Date Tax
    Involved employment, etc.)         at Issue           Claimed on Tax Return          Benefit Claimed    Return Filed

             (If additional space is required, please include information on a separate attachment to this schedule)
4. Transaction costs (i.e. fees and other amounts paid to promoters, attorneys, accountants, appraisers, or others to plan and carry
    out the transaction)
Tax Years                                         Transaction Costs paid to                                                  Amount(s)
    Involved            Name           Business                       Address                               Relationship       Paid

             (If additional space is required, please include information on a separate attachment to this schedule)
5. Other parties to the transaction (including but not limited to the names of employees who are affected by an employer's transactions)
             Party Name                EIN/SSN                                Address                       Daytime Phone Number

             (If additional space is required, please include information on a separate attachment to this schedule)
6. Are your tax matters with respect to this elected transaction currently in litigation                    Yes                No
7. Has the Service informed you it has designated (or is considering designation
                                                                                                            Yes                No
    of) your transaction for litigation
8. Are you currently a party to any bankruptcy proceeding                                                   Yes                No
Catalog No. 47521K                                        www.irs.gov                                       Form 13750 (10-2005)

- 4 -

Page 4 of 4
Details of Tax Advice
Schedule B (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)
Indicate the notice, ruling or other transaction description for the box checked in Section II to which this Schedule B applies

Tax Opinion Matters
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 Yes No
from consideration for relief under this section)

2. Did you receive the written tax opinion before filing the affected tax return(s) Yes No

3. Did you implement the transaction as described in the opinion. If No, complete item 4 Yes No
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) Yes No

Taxpayer – Tax Advisor Relationship Matters
6. Was a tax advisor recommended by a promoter of the transaction Yes No

7. Who recommended the tax advisor
8. Did you have a retainer or other agreement with the tax advisor setting forth
Yes No
the terms of engagement. (If Yes, include a copy with your election.)
9. Who paid the advisor's fees I did Another individual (Please provide individuals name)

10. How much were the advisor's fees (by year)
11. Were the advisor's fees contingent upon the intended tax benefits
Yes No
(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 Don't know Yes No
13. Additional information

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.
Catalog No. 47521K www.irs.gov Form 13750 (10-2005)

PDF file checksum: 1106159193

(Plugin #1/7.24/11.3)