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31.

Statement of Annual Income—Individual

Statement of Annual Income—Individual

Applicable year: _________

To Chief, Special Procedures Function Kind of Tax Compromised







From Name and address of taxpayer(s) Years or Periods Compromised

Social Security Number(s) and Employer Identification
  1. Adjusted gross income from line _____ of Form 1040 ("AGI") $ ______

  2. Add:
    1. Nontaxable income______

    2. Fair market value of gifts, bequests, etc. ______

    3. Losses from sale or exchange of property ______

    4. Pro rata share of partnership and S corp.

      losses from sale or exchange of property ______

    5. Deductions taken for IRA or contribution

      to self-employment retirement plan ______

    6. Deduction taken for NOL carry back/forward ______

    7. Pro rata share of undistributed income

      (above $10,000) of closely held corporations ______

    8. Other (attach explanation) ______

      Total additions and excluded deductions: ______ ______

  3. Sum of items 1 and 2 above: ______

  4. Less:
    1. Installment payments made under settlement during applicable year: ______

    2. Income taxes reported and paid with respect to applicable year:

      1. Federal $ ______

      2. State $ ______

      3. Local $ ______

        (If individual taxpayer files joint return with non-liable spouse, attach computation of subtractable portion of income taxes and specify percentage here: _______%. See paragraph 2 of collateral agreement.)

        Total subtractable income taxes: ______

        Total substractions: ______ _____

      4. Annual Income (item 3 minus item 4): $ _____

      5. Computation of payment due under the collateral agreement:

        1. Nothing for the first $________ of annual income.

        2. ___% of $ _______

          (annual income from $ _______ to $ _______) = $ ________

        3. ___% of $ _______

          (annual income from $ _______ to $ _______) = $ ________

        4. ___% of $ _______

          (annual income from $ _______ to $ _______) = $ ________

        5. ___% of $ _______

          (annual income from $ _______ to $ _______) = $ ________

        6. ___% of $ _______

        (annual income in excess of $ _______) = $ ________

        TOTAL PAYMENT DUE UNDER COLLATERAL AGREEMENT: $ ________

      6. Interest due on above amount (see paragraph 5 of the collateral agreement) $ ________

      7. Total amount due under the collateral agreement with respect to the applicable tax year. (Pay in full herewith.) $ ________

This statement of annual income for the applicable tax year indicated above is filed as required by the terms of a collateral agreement executed as part of a settlement respecting the tax liability for the periods shown above. I am attaching copies of my income tax returns (federal, state, and local if applicable), including any Forms W-2 and schedules, for the applicable tax year.

Under penalty of perjury, I declare that I have examined this statement and that it is true, correct, and complete.
___________________
Your Signature

___________________
Spouse's Signature if Joint

________________
Date

[cited in USAM 6-6.520]