Form 1120-SF U.S. Income Tax Return for Settlement Funds

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
DRAFT in your response. You may make comments
anonymously, or you may include your name and
e-mail address or phone number. We will be unable
to respond to all comments due to the high volume
we receive. However, we will carefully consider
each suggestion. So that we can properly consider
your comments, please send them to us within 30
days from the date the draft was posted.

1
TLS, have you
transmitted all R
text files for this
cycle update?

Date

Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 1120-SF, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
1
FLAT SIZE: 216 mm (8 ⁄ 2 ") 3 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

1120-SF

(Rev. December 2006)

Date

Signature

O.K. to print
Revised proofs
requested

U.S. Income Tax Return for Settlement Funds
(Under Section 468B)

Department of the Treasury
Internal Revenue Service

Please Type or Print

Action

f
o
s
a
6
t
0
f
0
a
2
r
/
D /25
0
1

OMB No. 1545-1394

For calendar year 20

Name of fund

Employer identification number of fund (see instructions)

Number, street, and room or suite no. (If a P.O. box, see instructions.)

City or town, state, and ZIP code

Name and address of administrator (defined on page 3 of the instructions)

Check applicable boxes: (1)

Part I

Final return

(2)

Name change

Income

1
2
3
4
5
6

Taxable interest
Dividends
Capital gain net income (attach Schedule D (Form 1120))
Items of income or gain from a partnership interest
Other income (attach schedule)
Gross income. Add lines 1 through 5

Deductions

7
8
9
10
11
12
13

Trustee/administrator fees
Taxes
Accounting and legal services (attach schedule)
Notification of claimants and claim processing expenses
Other deductions (attach schedule)
Net operating loss deduction
Total deductions. Add lines 7 through 12

16

Address change

Amended return

1
2
3
4
5
6
7
8
9
10
11
12
13

14
15

Modified gross income. Subtract line 13 from line 6
Total tax. Enter 35% of line 14
Credits and payments:
a Overpayment from prior year allowed
as a credit

b Current year estimated tax payments
c Refund of overpaid estimated tax
applied for on Form 4466

16a
16b
16c

d
e
f
17
18

16d
Subtract line 16c from the total of lines 16a and 16b
16e
Tax deposited with Form 7004
Total credits and payments (add lines 16d and 16e)
Estimated tax penalty (see page 4 of instructions). Check if Form 2220 is attached
Tax due. If the total of lines 15 and 17 is more than line 16f, enter amount owed

19

Overpayment. If line 16f is more than the total of lines 15 and 17, enter amount overpaid

20

Enter amount of line 19 you want: Credited to next year’s estimated tax
Refunded ©

Sign
Here

(4)

Tax Computation (see instructions)

Part II
14
15

(3)

Income and Deductions (see instructions)

©

16f
17
18
19

©

20

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
May the IRS discuss this return
with the preparer shown below
Yes
No
(see instructions)?
Signature of fund administrator
Date
Title

©

Paid
Preparer’s
Use Only

Preparer’s
signature

©

Firm’s name (or
yours if self-employed),
address, and ZIP code

©

Date

©

For Paperwork Reduction Act Notice, see page 4 of separate instructions.

Preparer’s SSN or PTIN

Check if
self-employed
EIN
Phone no.
Cat. No. 14989I

(

)

Form

1120-SF

(Rev. 12-2006)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 1120-SF, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
1
FLAT SIZE: 216 mm (8 ⁄ 2 ") 3 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1120-SF (Rev.12-2006)

Schedule L

Page

Balance Sheets
Assets

(a) Beginning of year

2

(b) End of year

f
o
s
a
6
t
0
f
0
a
2
r
/
D /25
0
1
1

1

Cash

2

U.S. Government obligations

3

State and local government obligations

3

4

Other investments (attach schedule)

4

5

Other assets (attach schedule)

6

Total assets. Add lines 1 through 5

7

Liabilities

8

Fund balance

9

Total. Add lines 7 and 8

2

5
6

Liabilities and Fund Balance

Additional Information

7
8
9

Yes No

1a Enter the amount of cash and the fair market value of property, valued at the date of the
transfer, transferred to the fund during the tax year
$
b For transfers of property included on line 1a, attach a copy of each qualified appraisal and the statements
received from a transferor under Regulations sections 1.468B-3(b) and 1.468B-3(e).
©
c Were amounts transferred to the fund during the tax year by a person other than a transferor?
2

Enter the amount of tax-exempt interest received or accrued during the tax year

3a Were direct and indirect distributions made to claimants during the tax year?
b If “Yes,” enter the amount of the total distributions

$
©

$

4a Did the fund make any distributions (including deemed distributions) to a transferor or related party during the
©
tax year?
b If “Yes,” enter the amount of the total distributions and attach a statement showing the name,
identifying number, and the amount of distributions to each transferor or related party
$
5a Check the type of liability (or liabilities) for which the fund was established.
Tort
Breach of Contract
Violation of Law
CERCLA
Other
b If “Other” is checked, enter the percent (by value) of the assets of the fund that are allocated to the “Other”
©
liability
%
Attach a statement describing the type of liability (or liabilities).
6

If the fund was established by a court order, enter the Court Order Number under which the
fund was established
Printed on recycled paper

Form

1120-SF

(Rev. 12-2006)