Department of the Treasury—Internal Revenue Service                                 Date received by
Form 870                                                                                                                    Internal Revenue Service
(Rev. March 1992)    Waiver of Restrictions on Assessment and Collection of
                     Deficiency in Tax and Acceptance of Overassessment
Names and address of taxpayers (Number, street, city or town, State, ZIP code)                           Social security or employer
                                                                                                         identification number

                                                Increase (Decrease) in Tax and Penalties
Tax year ended                      Tax                                                    Penalties

(For instructions, see back of form)
Consent to Assessment and Collection
I consent to the immediate assessment and collection of any deficiencies (increase in tax and penalties) and accept any overassessment (decrease in
tax and penalties) shown above, plus any interest provided by law. I understand that by signing this waiver, I will not be able to contest these years in
the United States Tax Court, unless additional deficiencies are determined for these years.

YOUR                                                                                                                             Date
SIGNATURE
HERE
SPOUSE'S                                                                                                                         Date
SIGNATURE

TAXPAYER'S                                                                                                                       Date
REPRESENTATIVE
HERE

CORPORATE
NAME

CORPORATE                                                                Title                                                Date
OFFICER(S)

SIGN HERE                                                                Title                                                Date

                                                        Catalog Number 16894U                                               Form 870 (Rev. 3-1992)

Name of Taxpayer:
Identification Number:
Form 870  page 2                                     Instructions

General Information
If you consent to the assessment of the deficiencies           We will consider this waiver a valid claim for refund or
shown in this waiver, please sign and return the form in       credit of any overpayment due you resulting from any
order to limit any interest charge and expedite the            decrease in tax and penalties shown above, provided
adjustment to your account. Your consent will not              you sign and file it within the period established by law
prevent you from filing a claim for refund (after you have     for making such a claim.
paid the tax) if you later believe you are so entitled. It will
not prevent us from later determining, if necessary, that
                                                               Who Must Sign
you owe additional tax; nor extend the time provided by
law for either action.                                         If you filed jointly, both you and your spouse must sign.
                                                               If this waiver is for a corporation, it should be signed with
We have agreements with State tax agencies under               the corporation name, followed by the signatures and
which information about Federal tax, including increases       titles of the corporate officers authorized to sign. An
or decreases, is exchanged with the States. If this            attorney or agent may sign this waiver provided such
change affects the amount of your State income tax, you        action is specifically authorized by a power of attorney
should file the required State form.                           which, if not previously filed, must accompany this form.

If you later file a claim and the Service disallows it, you    If this waiver is signed by a person acting in a fiduciary
may file suit for refund in a district court or in the United  capacity (for example, an executor, administrator, or a
States Claims Court, but you may not file a petition with      trustee) Form 56, Notice Concerning Fiduciary
the United States Tax Court.                                   Relationship, should, unless previously filed, accompany
                                                               this form.

                                                    Catalog Number 16894U                Form 870 (Rev. 3-1992)