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33.

Statement of Annual Income—Corporate

Statement of Annual Income—Corporate

Applicable year: ______

To Chief, Special Procedures Function





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



Social Security Number(s) and Employer Identification

  1. Taxable income from line _____ of Form 1120 ("TI") $ ______

  2. Add:
    1. Tax-exempt, excludable, or other nontaxable income $______

    2. Special deductions taken (dividends received, certain dividends paid, amortization of start-up costs, etc.,

      Code Sections 241 through 250) ______

    3. Losses from sale or exchange of property ______

    4. Deduction taken for NOL carry back/forward ______

    5. Pro rata share of undistributed income (over $10,000) of any partially owned subsidiaries not included on consolidated return_________

    6. 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 $ ______

    Total subtractable income taxes: ______

    Total substractions: ______ _____

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

  6. 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: $ ________

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

  8. 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 a copy of my income tax returns (federal, state, and local if applicable), including any 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.

__________________________
Signature of President or
Other Principal Officer

____________________
Title

__________
Date

[cited in USAM 6-6.520]