Ex. U


     
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 Number
_______________________________


1. Adjusted gross income from line ___ of Form 1040 ("AGI") $______
2. Add: (a) Nontaxable income $______
(b) Fair market value of gifts, bequests, etc.   ______
(c) Losses from sale or exchange of property   ______
(d) Pro rata share of partnership and S corp. losses from sale or exchange of property   ______
(e) Deductions taken for IRA or contribution to self-employment retirement plan   ______
(f) Deduction taken for NOL carry back/forward   ______
(g) Pro rata share of undistributed income   ______
(h) Other (attach explanation)   ______
    Total additions and excluded deductions:   ______   ______
3. Sum of items 1 and 2 above:   ______
4. Less: (a) Installment payments made under settlement during applicable year   ______
(b) 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 well as hypothetical separate tax returns or equivalent information, and specify percentage here:        %. See paragraphs 2 and 5 of collateral agreement.)

    Total subtractable income taxes

  ______
    Total substractions:   ______   ______
5. Annual Income (item 3 minus item 4): $______
6. Computation of payment due under the collateral agreement:
    (a) Nothing for the first $______ of annual income.
    (b) ____% of $______ (annual income from $______ to $______) = $______
    (c) ____% of $______ (annual income from $______ to $______) = $______
    (d) ____% of $______ (annual income from $______ to $______) = $______
    (e) ____% of $______ (annual income from $______ to $______) = $______
    (f) ____% 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 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

Statement of Annual Income -- Corporate
Applicable year: _____
To   Chief, Special Procedures Function
_____________________________________
Kind of Tax Compromised
_______________________________
From   Name and Address of Corporation Years or Periods Compromised
_______________________________
 
_____________________________________
Employer Identification No.
_______________________________


1. Adjusted gross income from line ___ of Form 1120 ("TI") $______
2. Add: (a) Tax-exempt, excludable, or other nontaxable income $______
(b) Special deductions taken (dividends received, certain dividends paid, amortization of start-up costs, etc., Code Sections 241 through 250)   ______
(c) Losses from sale or exchange of property   ______
(d) Deduction taken for NOL carry back/forward   ______
(e) Pro rata share of undistributed income (over $10,000) of any partially owned subsidiaries not included on consolidated return   ______
(f) Other (attach explanation)   ______
    Total additions and excluded deductions:   ______   ______
3. Sum of items 1 and 2 above:   ______
4. Less: (a) Installment payments made under settlement during applicable year   ______
(b) 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:
    (a) Nothing for the first $______ of annual income.
    (b) ____% of $______ (annual income from $______ to $______) = $______
    (c) ____% of $______ (annual income from $______ to $______) = $______
    (d) ____% of $______ (annual income from $______ to $______) = $______
    (e) ____% of $______ (annual income from $______ to $______) = $______
    (f) ____% of $______ (annual income in excess of $______) = $______
    TOTAL PAYMENT DUE UNDER COLLATERAL AGREEMENT: $______
7. Interest due on above amount (see paragraph 4 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

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Title Page || Contents || Section I || Section II || Section III
Section IV || Section V || Section VI || Appendices
Table of Cases and Authorities
Updated April 6, 2015

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