OMB No. 1545-0177
                                                         Casualties and Thefts
Form 4684                           Go to www.irs.gov/Form4684 for instructions and the latest information. 
Department of the Treasury                                        Attach to your tax return.                                       2022
Internal Revenue Service                       Use a separate Form 4684 for each casualty or theft.                                Attachment  
                                                                                                                                   Sequence No. 26
Name(s) shown on tax return                                                                                              Identifying number

SECTION  A—Personal  Use  Property              (Use  this  section  to  report  casualties  and  thefts  of  property  not     used  in  a  trade  or 
business or for income-producing purposes. For tax years 2018 through 2025, if you are an individual, casualty or theft losses 
of personal-use property are deductible only if the loss is attributable to a federally declared disaster. You must use a separate 
Form 4684 (through line 12) for each casualty or theft event involving personal-use property.                        If reporting a qualified disaster 
loss, see the instructions for special rules that apply before completing this section.)
If the casualty or theft loss is attributable to a federally declared disaster, check here                 and enter the DR-      or EM-
declaration number assigned by FEMA. (See instructions.)
   1 Description of properties (show type, location (city, state, and ZIP code), and date acquired for each property). Use a separate line for each 
     property lost or damaged from the same casualty or theft. If you checked the box and entered the FEMA disaster declaration number above, 
     enter the ZIP code for the property most affected on the line for Property A.
                              Type of Property                             City and State                              ZIP Code      Date Acquired
     Property A
     Property B
     Property C
     Property D
                                                                                                               Properties
                                                                                   A                       B                C              D
   2 Cost or other basis of each property  .   .  .    . .     .    2 
   3 Insurance  or  other  reimbursement  (whether  or  not  you 
     filed a claim) (see instructions) . . .   .  .    . .     .    3 
     Note: If line 2 is more than line 3, skip line 4.
   4 Gain from casualty or theft. If line 3 is more than line 2, 
     enter the difference here and skip lines 5 through 9 for 
     that column. See instructions if line 3 includes insurance 
     or  other  reimbursement  you  did  not  claim,  or  you 
     received payment for your loss in a later tax year  .     .    4
   5 Fair market value before casualty or theft   .    . .     .    5 
   6 Fair market value after casualty or theft  . .    . .     .    6 
   7 Subtract line 6 from line 5  . .    . .   .  .    . .     .    7 
   8 Enter the smaller of line 2 or line 7 .   .  .    . .     .    8 
   9 Subtract line 3 from line 8. If zero or less, enter -0- . .    9 
10   Casualty or theft loss. Add the amounts on line 9 in columns A through D  .     . .      . .        . .   . .   . . .  .   10 
11   Enter $100 ($500 if qualified disaster loss rules apply; see instructions)  . . . .      . .        . .   . .   . . .  .   11 
12   Subtract line 11 from line 10. If zero or less, enter -0-  . . .  . . .       . . .      . .        . .   . .   . . .  .   12 
     Caution: Use only one Form 4684 for lines 13 through 18.
13   Add the amounts on line 4 of all Forms 4684       . .     .  . .  . . .       . . .      . .        . .   . .   . . .  .   13 
14   Add the amounts on line 12 of all Forms 4684. If you have losses not attributable to a federally declared disaster, see 
     the instructions  .    . .  .  .    . .   .  .    . .     .  . .  . . .       . . .      . .        . .   . .   . . .  .   14 
     Caution: See instructions before completing line 15. 
15   • If line 13 is more than line 14, enter the difference here and on Schedule D.   Do not 
     complete the rest of this section.
     • If line 13 is equal to line 14, enter -0- here. Do not complete the rest of this section.
     • If line 13 is less than line 14, and you have no qualified disaster losses subject to the 
     $500 reduction on line 11 on any Form(s) 4684, enter -0- here and go to line 16. If you 
     have qualified disaster losses subject to the $500 reduction, subtract line 13 from line 14           .   . .   . . .  .   15 
     and enter the smaller of this difference or the amount on line 12 of the Form(s) 4684 
     reporting those losses. Enter that result here and on Schedule A (Form 1040), line 16; or 
     Schedule A (Form 1040-NR), line 7. If you claim the standard deduction, also include on 
     Schedule  A  (Form  1040),  line  16,  the  amount  of  your  standard  deduction  (see  the 
     Instructions  for  Form  1040).  Do  not  complete  the  rest  of  this  section  if  all  of  your 
     casualty or theft losses are subject to the $500 reduction.
                                                                                                         }
16   Add lines 13 and 15. Subtract the result from line 14  .     . .  . . .       . . .      . .        . .   . .   . . .  .   16 
17   Enter 10% of your adjusted gross income from Form 1040, 1040-SR, or 1040-NR, line 11. Estates and trusts, see 
     instructions  .     .  . .  .  .    . .   .  .    . .     .  . .  . . .       . . .      . .        . .   . .   . . .  .   17
18   Subtract line 17 from line 16. If zero or less, enter -0-. Also, enter the result on Schedule A (Form 1040), line 15; or 
     Schedule A (Form 1040-NR), line 6. Estates and trusts, enter the result on the “Other deductions” line of your tax return  18
For Paperwork Reduction Act Notice, see instructions.                                  Cat. No. 12997O                               Form 4684 (2022)

Form 4684 (2022)                                                         Attachment Sequence No.  26                                                                 Page 2
Name(s) shown on tax return. Do not enter name and identifying number if shown on other side.                                             Identifying number

SECTION B—Business and Income-Producing Property
Part I     Casualty or Theft Gain or Loss (Use a separate Part l for each casualty or theft.)
19 Description of properties (show type, location, and date acquired for each property). Use a separate line for each property lost or damaged from 
   the same casualty or theft. See instructions if claiming a loss due to a Ponzi-type investment scheme and Section C is not completed.
   Property A
   Property B
   Property C
   Property D
                                                                                                                         Properties
                                                                                               A                       B                       C                    D
20 Cost or adjusted basis of each property .        .  .   .     .         20
21 Insurance  or  other  reimbursement  (whether  or  not  you 
   filed a claim). See the instructions for line 3 .   .   .     .         21 
   Note: If line 20 is more than line 21, skip line 22.
22 Gain from casualty or theft. If line 21 is more than line 20, enter 
   the difference here and on line 29 or line 34, column (c), except 
   as provided in the instructions for line 33. Also, skip lines 23 
   through 27 for that column. See the instructions for line 4 if line 
   21  includes  insurance  or  other  reimbursement  you  did  not 
   claim, or you received payment for your loss in a later tax year        22
23 Fair market value before casualty or theft       .  .   .     .         23
24 Fair market value after casualty or theft .      .  .   .     .         24 
25 Subtract line 24 from line 23      .  .    .   . .  .   .     .         25
26 Enter the smaller of line 20 or line 25        . .  .   .     .         26
   Note: If the property was totally destroyed by     casualty or 
   lost from theft, enter on line 26 the amount from line 20.
27 Subtract line 21 from line 26. If zero or less, enter -0-  .            27
28 Casualty or theft loss. Add the amounts on line 27. Enter the total here and on line 29  orline 34. See instructions                   .    .       28
Part II    Summary of Gains and Losses (from separate Parts l)                                                    (b)  Losses from casualties or thefts        (c)  Gains from 
                                                                                                              (i) Trade, business, 
                                 (a)  Identify casualty or theft                                              rental, or royalty          (ii) Income-    casualties or thefts 
                                                                                                                   property          producing property   includible in income
                                         Casualty or Theft of Property Held One     Year or Less                                                               
29                                                                                                          (                    ) (                     )
                                                                                                            (                    ) (                     )
30 Totals. Add the amounts on line 29         .   . .  .   .     .     .   .     .     .   .     .       30 (                    ) (                     )
31 Combine line 30, columns (b)(i) and (c). Enter the net gain or (loss) here and on Form 4797, line 14. If Form 4797 is 
   not otherwise required, see instructions .       .  .   .     .     .   .     .     .   .     .     . .  .    . .   . .  .      .    . .    .       31
32 Enter the amount from line 30, column (b)(ii), here. Individuals, enter the amount from income-producing property on 
   Schedule A (Form 1040), line 16; or Schedule A (Form 1040-NR), line 7. (Do not include any loss on property used as 
   an employee.) Estates and trusts, partnerships, and S corporations, see instructions .                        . .   . .  .      .    . .    .       32
                                        Casualty or Theft of Property Held More Than One Year
33 Casualty     or theft gains from Form 4797, line 32 . . . . . . . . . . . . . . . . . . . . . . . . .                                               33      
34                                                                                                          (                    ) (                     )
                                                                                                            (                    ) (                     )
35 Total losses. Add amounts on line 34, columns (b)(i) and (b)(ii) . . . . .                            35 (                    ) (                     )
36 Total gains. Add lines 33 and 34, column (c) .      .   .     .     .   .     .     .   .     .     . .  .    . .   . .  .      .    . .    .       36
37 Add amounts on line 35, columns (b)(i) and (b)(ii)      .     .     .   .     .     .   .     .     . .  .    . .   . .  .      .    . .    .       37
38 If the loss on line 37 is more than the gain on line 36:
a Combine line 35, column (b)(i), and line 36, and enter the net gain or (loss) here. Partnerships and S corporations, see 
   the  Note below. All others, enter this amount on Form 4797, line 14. If Form 4797 is not otherwise required, see 
   instructions    .     . .   . .    .  .    .   . .  .   .     .     .   .     .     .   .     .     . .  .    . .   . .  .      .    . .    .  38a
b Enter the amount from line 35, column (b)(ii), here. Individuals, enter the amount from income-producing property on 
   Schedule A (Form 1040), line 16; or Schedule A (Form 1040-NR), line 7. (Do not include any loss on property used as 
   an  employee.)  Estates  and  trusts,  enter  on  the  “Other  deductions”  line  of  your  tax  return.  Partnerships  and  S 
   corporations, see the Note below .         .   . .  .   .     .     .   .     .     .   .     .     . .  .    . .   . .  .      .    . .    .  38b
39 If the loss on line 37 is less than or equal to the gain on line 36, combine lines 36 and 37 and enter here. Partnerships,
   see the Note below. All others, enter this amount on Form 4797, line 3  .                     .     . .  .    . .   . .  .      .    . .    .       39
   Note: Partnerships, enter the amount from line 38a, 38b, or 39 on Form 1065, Schedule K, line 11. 
   S corporations, enter the amount from line 38a or 38b on Form 1120-S, Schedule K, line 10.
                                                                                                                                                          Form 4684 (2022)

Form 4684 (2022)                                            Attachment Sequence No.  26                                            Page 3
Name(s) shown on tax return                                                                                      Identifying number

SECTION C—Theft Loss Deduction for Ponzi-Type Investment Scheme Using the Procedures in Revenue 
Procedure 2009-20 (Complete this section in lieu of Appendix A in Revenue Procedure 2009-20. See instructions.)
Part I  Computation of Deduction
40 Initial investment .     . . . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  40
41 Subsequent investments (see instructions)  .    .  . . . . . .            . .  .  .     . . .  41
42 Income reported on your tax returns for tax years prior to the discovery year  
   (see instructions)       . . . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  42
43 Add lines 40, 41, and 42     . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  43
44 Withdrawals for all years (see instructions)  . .  . . . . . .            . .  .  .     . . .  44
45 Subtract line 44 from line 43. This is your total qualified investment  . . .  .  .     . . .  45
46 Enter 0.95 (95%) if you have no potential third-party recovery. Enter 0.75 (75%) if you have 
   potential third-party recovery  . . .   .    .  .  . . . . . .            . .  .  .     . . .  46             .
47 Multiply line 46 by line 45  . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  47
48 Actual recovery  .       . . . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  48
49 Potential insurance/Securities Investor Protection Corporation (SIPC) recovery    .     . . .  49
50 Add lines 48 and 49. This is your total recovery . . . . . . .            . .  .  .     . . .  50
51 Subtract line 50 from line 47. This is your deductible theft loss. Include this amount on line 
   28 of Section B, Part I. Do not complete lines 19–27 for this loss. Then complete Section B, 
   Part II  .    . . .      . . . .  . .   .    .  .  . . . . . .            . .  .  .     . . .  51
Part II Required Statements and Declarations (See instructions.)
• I am claiming a theft loss deduction pursuant to Revenue Procedure 2009-20 from a specified fraudulent arrangement conducted by the following 
individual or entity.
Name of individual or entity
Taxpayer identification number (if known)  
Address
• I have written documentation to support the amounts reported in Part I of this Section C.
• I am a qualified investor, as defined in section 4.03 of Revenue Procedure 2009-20.
• If I have determined the amount of my theft loss deduction using 0.95 on line 46 above, I declare that I have not pursued and do not intend to pursue 
any potential third-party recovery, as that term is defined in section 4.10 of Revenue Procedure 2009-20.
• I agree to comply with the conditions and agreements set forth in Revenue Procedure 2009-20 and this Section C.
• If I have already filed a return or amended return that does not satisfy the conditions in section 6.02 of Revenue Procedure 2009-20, I agree to all 
adjustments or actions that are necessary to comply with those conditions. The tax year(s) for which I filed the return(s) or amended return(s) and the 
date(s) on which they were filed are as follows:

                                                                                                                  Form 4684 (2022)

Form 4684 (2022)                    Attachment Sequence No.  26                                                                                     Page 4
Name(s) shown on tax return                                                                                     Identifying number

SECTION D—Election To Deduct Federally Declared Disaster Loss in Preceding Tax Year (See instructions.)
Part I  Election Statement
By providing all of the information below, the taxpayer elects, under section 165(i) of the Internal Revenue Code, to deduct a loss attributable to a federally 
declared disaster and that occurred in a federally declared disaster area in the tax year immediately preceding the tax year the loss was sustained.
Attach this Section D to your return or amended return for the tax year immediately preceding the tax year the loss was sustained to claim the disaster 
loss deduction.
52 Provide the name or a description of the federally declared disaster.

53 Provide the date or dates (mm/dd/yyyy) of the loss or losses attributable to the federally declared disaster.

54 Specify the address, including the city or town, county or parish, state, and ZIP code where the damaged or destroyed property was located at
   the time of the disaster.

Part II Revocation of Prior Election
By providing all of the information below, the taxpayer revokes the prior election under section 165(i) of the Internal Revenue Code to deduct a loss 
attributable to a federally declared disaster and that occurred in a federally declared disaster area in the tax year immediately preceding the tax year 
the loss was sustained.
Attach this Section D to your amended return for the tax year immediately preceding the tax year the loss was sustained to remove the previous 
disaster loss deduction.
55 Provide the name or a description of the federally declared disaster and the address of the property that was damaged or destroyed and for
   which the election was claimed.

56 Specify the date (mm/dd/yyyy) you filed the prior election, which you are now revoking. (See instructions and note that new rules went into effect 
   on October 13, 2016.)
57 Enclose your payment or otherwise provide evidence for, or explanation of, your arrangements for the repayment of the amount of any credit or
   refund which you received and which resulted from the prior election (which you are now revoking).

                                                                                                                Form 4684 (2022)