21.	Proposed Restitution Order

DEFENDANT: CASE NUMBER: CRIMINAL MONETARY PENALTIES The defendant must pay the total criminal monetary penalties under the Schedule of Payments.
Total Assessment	Total Fine	Total Restitution
		[ enter total amount ]
The defendant must make restitution to the following victim(s) in the amount(s) listed below. Name of Victim: Internal Revenue Service The total amount of restitution the defendant shall make to the Internal Revenue Service consists of the following:[FN1]

Tax Year(s) or Period(s) and Items (describe in detail)	Amount to be credited to tax	Interest Under the Internal Revenue Code Due Through _________*
Total:

*This interest figure has been calculated by the IRS under 26 U.S.C. 6601 and/or 6621, as of the anticipated date of sentencing. This interest figure does not include any interest that may accrue under 18 U.S.C. 3612.
Name of Victim: [ list other victims and restitution amounts ordered if applicable ]
Total Restitution ordered:    $_____________
[ ]	Restitution amount ordered pursuant to plea agreement $_______________
[ ]	The defendant must pay interest on restitution and on a fine of more than $2,500, unless the restitution or fine is paid in full before the fifteenth day after the date of the judgment, pursuant to 18 U.S.C. § 3612(f). All of the payment options on the Restitution Order and payment schedule may be subject to penalties for delinquency and default, pursuant to 18 U.S.C. 3612(g).
[ ]	The court determined that the defendant does not have the ability to pay interest that might accrue under 18 U.S.C. 3612 and it is ordered that: [ ] the interest requirement is waived for the [ ] fine      [ ] restitution [ ] the interest requirement for the [ ] fine      [ ] restitution is modified as follows:

DEFENDANT: CASE NUMBER: RESTITUTION ORDER AND SCHEDULE OF PAYMENTS[FN2] Defendant is ordered to pay restitution in the total amount of $______________ under 18 U.S.C. [ 3663/3663A ] Having assessed the defendant's ability to pay [if restitution is ordered under 18 U.S.C. 3663A, ability to pay is not relevant], payment of the restitution is due as follows: A     [ ] Lump sum payment of $ ____________ due immediately, balance due (if any) [ ] not later than __________________, or [ ] in accordance with [ ] C, [ ] D, or [ ] E below; or B     [ ] Payment to begin immediately (may be combined with [ ] C or [ ] E below); or C     [ ] Payment in equal ___________ (e.g., weekly, monthly, quarterly) installments of $ ________ over a period of ______________ (e.g. months or years), to commence _____________ (e.g. 30 or 60 days) after the date of this judgment; or D     [ ] Payment in equal _____________ (e.g., weekly, monthly, quarterly) installments of $______ over a period of ______________ (e.g. months or years), to commence _____________ (e.g., 30 or 60 days) after release from imprisonment to a term of supervision; or E     [ ] Special instructions regarding the payment of restitution: Unless the court has expressly ordered otherwise, if this judgment imposes imprisonment, payment of restitution is due and payable immediately and, if necessary, during imprisonment through participation in BOP's Inmate Financial Responsibility Program. The BOP is directed to deduct from the defendant's resources the maximum amount permitted under 28 C.F.R. 545.11. Upon release, the defendant shall make monthly payments of not less than $ [  ]. This monthly amount may be adjusted in accordance with 18 U.S.C. 3664(k). The defendant is obligated to report to the Government and the Court any material change in [ his/her ] economic circumstances, pursuant to 18 U.S.C. 3664(k). Defendant shall make all restitution payments, except those payments made through the Federal Bureau of Prisons, to: United States District Court for the [ ] District of [ ] Clerk's Office Attn: Financial Section [ insert appropriate address ] The defendant shall include, with his [her] payment(s) to the District Court, his [her] name and social security number, the District Court's docket number assigned to this case, the tax year(s) or period(s) for which restitution has been ordered, and a request that this information be sent, along with the payment(s), to the appropriate office of the Internal Revenue Service. The Clerk's Office shall send the defendant's restitution payment(s), along with the information provided by the defendant, to the Internal Revenue Service at the following address: IRS - RACS Attn: Mail Stop 6261, Restitution 333 W. Pershing Ave. Kansas City, MO 64108 [ judge's signature-if appropriate in your district ] FN 1. In cases involving employment taxes, be sure to include the tax period, type of tax, and the name of the applicable individual or entity. Examples of the type of tax include § 3101 Employee FICA, § 3111 Employer FICA, § 3401 ITW, and § 3301 FUTA. Here is a sample:

Tax Period	Type of Tax	Name of Individual/ Entity on Applicable Return (if different than defendant's)	Amount of Tax
Ex: 12/2010, 03/2011	Ex: § 3101 Employee FICA	Ex: John Doe, X Corporation
TOTAL:

FN 2. Prosecutors should check to see if the judges in their district sign restitution orders separately from the rest of the judgment. If so, make the appropriate changes to the restitution order form. [updated July 2011] [cited in USAM 6-4.370; Tax Resource Manual 18]