Federal Trade Commission Financial Statement of Individual Defendant 

FEDERAL TRADE COMMISSION 

FINANCIAL STATEMENT OF INDIVIDUAL DEFENDANT 

 

Definitions and Instructions: 

1. Complete all items. Enter “None” or “N/A” (“Not Applicable”) in the first field only of any item that does not apply 

to you. If you cannot fully answer a question, explain why. 

2. “Dependents” include your spouse, live-in companion, dependent children, or any other person, whom you or your 

spouse (or your children’s other parent) claimed or could have claimed as a dependent for tax purposes at any 

time during the past five years. 

3. “Assets” and “Liabilities” include ALL assets and liabilities, located within the United States or any foreign country 

or territory, whether held individually or jointly and whether held by you, your spouse, or your dependents, or held 

by others for the benefit of you, your spouse, or your dependents. 

4. Attach continuation pages as needed. On the financial statement, state next to the Item number that the Item is 

being continued. On the continuation page(s), identify the Item number(s) being continued. 

5. Type or print legibly. 

6. Initial each page in the space provided in the lower right corner. 

7. Sign and date the completed financial statement on the last page. 

Penalty for False Information: 

Federal law provides that any person may be imprisoned for not more than five years, fined, or both, if such person: 

 (1) “in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the 

United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or devise a material fact; 

makes any materially false, fictitious or fraudulent statement or representation; or makes or uses any false writing or 

document knowing the same to contain any materially false, fictitious or fraudulent statement or entry” (18 U.S.C. § 1001); 

 (2) “in any . . . statement under penalty of perjury as permitted under section 1746 of title 28, United States Code, 

willfully subscribes as true any material matter which he does not believe to be true” (18 U.S.C. § 1621); or 

 (3) “in any ( . . . statement under penalty of perjury as permitted under section 1746 of title 28, United States 

Code) in any proceeding before or ancillary to any court or grand jury of the United States knowingly makes any false 

material declaration or makes or uses any other information . . . knowing the same to contain any false material 

declaration” (18 U.S.C. § 1623). 

For a felony conviction under the provisions cited above, federal law provides that the fine may be not more than the 

greater of (i) $250,000 for an individual or $500,000 for a corporation, or (ii) if the felony results in pecuniary gain to any

person or pecuniary loss to any person other than the defendant, the greater of twice the gross gain or twice the gross 

loss. 18 U.S.C. § 3571.
 

 1 of 10 Federal Trade Commission Financial Statement of Individual Defendant

BACKGROUND INFORMATION

Item 1. Information About You 

Full Name Social Security No.

 

Current Address of Primary Residence

 

Driver’s License No.

 

State Issued

 

Phone Numbers

Home: ( ) 

Fax: ( ) 

Date of Birth: / /

 (mm/dd/yyyy)

Place of Birth

Rent Own From (Date): / /

 (mm/dd/yyyy)

E-Mail Address

Internet Home Page

 

Previous Addresses for past five years (if required, use additional pages at end of form)

Address

 From: / / Until: / / 

 (mm/dd/yyyy) (mm/dd/yyyy)

Rent Own 

Address

 From: / / Until: / / 

Rent Own 

Address

 From: / / Until: / / 

Rent Own 

Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they 

were used: 

Item 2. Information About Your Spouse or Live-In Companion

Spouse/Companion's Name

 

Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Address (if different from yours)

 

Phone Number

( )

Place of Birth

 

Rent Own From (Date): / /

 (mm/dd/yyyy)

Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used:

 

Employer’s Name and Address 

 

Job Title 

Years in Present Job

 

Annual Gross Salary/Wages 

$ 

Item 3. Information About Your Previous Spouse

Name and Address

 

Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Item 4. Contact Information (name and address of closest living relative other than your spouse) 

Name and Address

 

Phone Number

( ) 

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 2 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 5. Information About Dependents (whether or not they reside with you)

Name and Address

 

Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Relationship

Name and Address

 

Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Relationship

 

Name and Address

 Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Relationship

 

Name and Address

 Social Security No.

 

Date of Birth

 / / 

(mm/dd/yyyy)

Relationship

 

Item 6. Employment Information/Employment Income

Provide the following information for this year-to-date and for each of the previous five full years, for each business entity of which you were a director, 

officer, member, partner, employee (including self-employment), agent, owner, shareholder, contractor, participant or consultant at any time during that 

period. “Income” includes, but is not limited to, any salary, commissions, distributions, draws, consulting fees, loans, loan payments, dividends, 

royalties, and benefits for which you did not pay (e.g., health insurance premiums, automobile lease or loan payments) received by you or anyone else 

on your behalf.

Company Name and Address

 Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

From (Month/Year)

 / 

To (Month/Year)

 / 

Year Income

20 $

Ownership Interest? Yes No $ 

Positions Held From (Month/Year) To (Month/Year) $ 

/ / $ 

/ / $ 

/ / $ 

Company Name and Address

 Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

From (Month/Year)

 / 

To (Month/Year)

 / 

Year Income

20 $

Ownership Interest? Yes No $ 

Positions Held From (Month/Year) To (Month/Year) $ 

/ / $ 

/ / $ 

/ / $ 

Company Name and Address

 Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

From (Month/Year)

 / 

To (Month/Year)

 / 

Year Income

20 $

Ownership Interest? Yes No $ 

Positions Held From (Month/Year) To (Month/Year) $ 

/ / $ 

/ / $ 

/ / $ 

Initials: 
 

 3 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 7. Pending Lawsuits Filed By or Against You or Your Spouse

List all pending lawsuits that have been filed by or against you or your spouse in any court or before an administrative agency in the United States or in 

any foreign country or territory. Note: At Item 12, list lawsuits that resulted in final judgments or settlements in your favor. At Item 21, list lawsuits that 

resulted in final judgments or settlements against you.

Caption of Proceeding Court or Agency and Location Case No. Nature of 

Proceeding Relief Requested Status or 

Disposition

Item 8. Safe Deposit Boxes

List all safe deposit boxes, located within the United States or in any foreign country or territory, whether held individually or jointly and whether held by 

you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents.

Name of Owner(s) Name & Address of Depository Institution Box No. Contents

Initials: 
 

 4 of 10 Federal Trade Commission Financial Statement of Individual Defendant

FINANCIAL INFORMATION

REMINDER: When an item asks for information regarding your “assets” and “liabilities” include ALL assets and liabilities, located within 

the United States or in any foreign country or territory, or institution, whether held individually or jointly, and whether held by you, your 

spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents. In addition, provide 

all documents requested in Item 24 with your completed Financial Statement. 

ASSETS

Item 9. Cash, Bank, and Money Market Accounts

List cash on hand (as opposed to cash in bank accounts or other financial accounts) and all bank accounts, money market accounts, or other financial 

accounts, including but not limited to checking accounts, savings accounts, and certificates of deposit. The term “cash on hand” includes but is not 

limited to cash in the form of currency, uncashed checks, and money orders.

a. Amount of Cash on Hand $ Form of Cash on Hand 

b. Name on Account Name & Address of Financial Institution Account No. Current Balance

$

$

$

$

$

Item 10. Publicly Traded Securities 

List all publicly traded securities, including but not limited to, stocks, stock options, corporate bonds, mutual funds, U.S. government securities (including 

but not limited to treasury bills and treasury notes), and state and municipal bonds. Also list any U.S. savings bonds.

Owner of Security

 

Issuer

 

Type of Security

 

No. of Units Owned

 

Broker House, Address

 

Broker Account No.

Current Fair Market Value

$ 

Loan(s) Against Security

$ 

Owner of Security

 

Issuer

 

Type of Security

 

No. of Units Owned

 

Broker House, Address

 

Broker Account No.

Current Fair Market Value

$ 

Loan(s) Against Security

$ 

Owner of Security

 

Issuer

 

Type of Security

 

No. of Units Owned

 

Broker House, Address

 

Broker Account No.

Current Fair Market Value

$ 

Loan(s) Against Security

$ 

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 5 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 11. Non-Public Business and Financial Interests

List all non-public business and financial interests, including but not limited to any interest in a non-public corporation, subchapter-S corporation, limited 

liability corporation (“LLC”), general or limited partnership, joint venture, sole proprietorship, international business corporation or personal investment 

corporation, and oil or mineral lease.

Entity’s Name & Address Type of Business or Financial 

Interest (e.g., LLC, partnership)

Owner

(e.g., self, spouse)

Ownership 

% 

If Officer, Director, Member 

or Partner, Exact Title

Item 12. Amounts Owed to You, Your Spouse, or Your Dependents

Debtor’s Name & Address

 

Date Obligation 

Incurred (Month/Year)

/

Original Amount Owed

$ 

Nature of Obligation (if the result of a final court 

judgment or settlement, provide court name 

and docket number)

Current Amount Owed $ Payment Schedule

$ 

Debtor’s Telephone

 

Debtor’s Relationship to You

 

Debtor’s Name & Address

 

Date Obligation 

Incurred (Month/Year)

/

Original Amount Owed

$ 

Nature of Obligation (if the result of a final court 

judgment or settlement, provide court name 

and docket number)

Current Amount Owed $ Payment Schedule

$ 

Debtor’s Telephone

 

Debtor’s Relationship to You

 

Item 13. Life Insurance Policies 

List all life insurance policies (including endowment policies) with any cash surrender value.

Insurance Company’s Name, Address, & Telephone No.

 

Beneficiary Policy No. Face Value

$

Insured

 

Loans Against Policy

$ 

Surrender Value

$ 

Insurance Company’s Name, Address, & Telephone No.

 

Beneficiary

 

Policy No.

 

Face Value

$ 

Insured

 

Loans Against Policy

$ 

Surrender Value

$ 

Item 14. Deferred Income Arrangements

List all deferred income arrangements, including but not limited to, deferred annuities, pensions plans, profit-sharing plans, 401(k) plans, IRAs, Keoghs, 

other retirement accounts, and college savings plans (e.g., 529 Plans).

Trustee or Administrator’s Name, Address & Telephone No.

 

Name on Account

 

Account No.

 

Date Established

 / / 

(mm/dd/yyyy)

Type of Plan

 

Surrender Value before 

Taxes and Penalties 

$

Trustee or Administrator’s Name, Address & Telephone No.

 

Name on Account Account No.

Date Established

 / / 

Type of Plan

 

Surrender Value before 

Taxes and Penalties 

$

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 6 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 15. Pending Insurance Payments or Inheritances

List any pending insurance payments or inheritances owed to you.

Type Amount Expected Date Expected (mm/dd/yyyy)

$ / /

$ / /

$ / /

Item 16. Vehicles

List all cars, trucks, motorcycles, boats, airplanes, and other vehicles.

Vehicle Type Year Registered Owner’s Name Purchase Price

$

Original Loan Amount

$

Current Balance

$

Make Registration State & No. Account/Loan No. Current Value

$

Monthly Payment

$

Model

 

Address of Vehicle’s Location

 

Lender’s Name and Address

 

Vehicle Type Year Registered Owner’s Name Purchase Price

$

Original Loan Amount

$

Current Balance

$

Make Registration State & No. Account/Loan No. Current Value

$

Monthly Payment

$

Model

 

Address of Vehicle’s Location

 

Lender’s Name and Address

 

Vehicle Type Year Registered Owner’s Name Purchase Price

$

Original Loan Amount

$

Current Balance

$

Make Registration State & No. Account/Loan No. Current Value

$

Monthly Payment

$

Model

 

Address of Vehicle’s Location

 

Lender’s Name and Address

 

Vehicle Type Year Registered Owner’s Name Purchase Price

$

Original Loan Amount

$

Current Balance

$

Make Registration State & No. Account/Loan No. Current Value

$

Monthly Payment

$

Model

 

Address of Vehicle’s Location

 

Lender’s Name and Address

 

Item 17. Other Personal Property

List all other personal property not listed in Items 9-16 by category, whether held for personal use, investment or any other reason, including but not 

limited to coins, stamps, artwork, gemstones, jewelry, bullion, other collectibles, copyrights, patents, and other intellectual property. 

Property Category

(e.g., artwork, jewelry) Name of Owner Property Location Acquisition Cost Current Value

$ $

$ $

$ $

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 7 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 18. Real Property

List all real property interests (including any land contract) 

Property’s Location

 

Type of Property

 

Name(s) on Title or Contract and Ownership Percentages

 

Acquisition Date (mm/dd/yyyy)

/ /

Purchase Price

$

Current Value

$

Basis of Valuation

Lender’s Name and Address

 

Loan or Account No.

 

Current Balance On First Mortgage or 

Contract

$

Monthly Payment

$

Other Mortgage Loan(s) (describe)

 

Monthly Payment

$

Rental Unit

Monthly Rent Received

$

Current Balance

$

Property’s Location

 

Type of Property

 

Name(s) on Title or Contract and Ownership Percentages

 

Acquisition Date (mm/dd/yyyy)

 / / 

Purchase Price

$

Current Value

$

Basis of Valuation

Lender’s Name and Address

 

Loan or Account No.

 

Current Balance On First Mortgage or 

Contract

$

Monthly Payment

$

Other Mortgage Loan(s) (describe)

 

Monthly Payment

$

Rental Unit

Monthly Rent Received

$ Current Balance

$

LIABILITIES

Item 19. Credit Cards 

List each credit card account held by you, your spouse, or your dependents, and any other credit cards that you, your spouse, or your dependents use, 

whether issued by a United States or foreign financial institution.

Name of Credit Card (e.g., Visa, 

MasterCard, Department Store) Account No. Name(s) on Account Current Balance

$

$

$

$

$

Item 20. Taxes Payable

List all taxes, such as income taxes or real estate taxes, owed by you, your spouse, or your dependents. 

Type of Tax Amount Owed Year Incurred

$

$

$

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 8 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 21. Other Amounts Owed by You, Your Spouse, or Your Dependents

List all other amounts, not listed elsewhere in this financial statement, owed by you, your spouse, or your dependents. 

Lender/Creditor’s Name, Address, and Telephone No.

 

Nature of Debt (if the result of a court judgment or settlement, provide court name and docket 

number)

 

Lender/Creditor’s Relationship to You

 

Date Liability Was Incurred

 / / 

(mm/dd/yyyy)

Original Amount Owed

$ 

Current Amount Owed

$ 

Payment Schedule

 

Lender/Creditor’s Name, Address, and Telephone No.

 

Nature of Debt (if the result of a court judgment or settlement, provide court name and docket 

number)

 

Lender/Creditor’s Relationship to You

 

Date Liability Was Incurred

 / / 

(mm/dd/yyyy)

Original Amount Owed

$ 

Current Amount Owed

$ 

Payment Schedule

 

OTHER FINANCIAL INFORMATION

Item 22. Trusts and Escrows

List all funds and other assets that are being held in trust or escrow by any person or entity for you, your spouse, or your dependents. Include any legal 

retainers being held on your behalf by legal counsel. Also list all funds or other assets that are being held in trust or escrow by you, your spouse, or your 

dependents, for any person or entity. 

Trustee or Escrow Agent’s Name & Address Date Established

(mm/dd/yyyy) Grantor Beneficiaries Present Market Value of Assets*

/ / $

/ / $

/ / $

*If the market value of any asset is unknown, describe the asset and state its cost, if you know it.

Item 23. Transfers of Assets 

List each person or entity to whom you have transferred, in the aggregate, more than $5,000 in funds or other assets during the previous five years by 

loan, gift, sale, or other transfer (exclude ordinary and necessary living and business expenses paid to unrelated third parties). For each such person or 

entity, state the total amount transferred during that period.

Transferee’s Name, Address, & Relationship Property Transferred Aggregate Value* Transfer Date

(mm/dd/yyyy)

Type of Transfer

(e.g., Loan, Gift)

$ / /

$ / /

$ / /

*If the market value of any asset is unknown, describe the asset and state its cost, if you know it.

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 9 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 24. Document Requests 

Provide copies of the following documents with your completed Financial Statement.

Federal tax returns filed during the last three years by or on behalf of you, your spouse, or your dependents. 

All applications for bank loans or other extensions of credit (other than credit cards) that you, your spouse, or your 

dependents have submitted within the last two years, including by obtaining copies from lenders if necessary.

Item 9 For each bank account listed in Item 9, all account statements for the past 3 years.

Item 11

For each business entity listed in Item 11, provide (including by causing to be generated from accounting records) the 

most recent balance sheet, tax return, annual income statement, the most recent year-to-date income statement, and all 

general ledger files from account records.

Item 17

All appraisals that have been prepared for any property listed in Item 17, including appraisals done for insurance 

purposes. You may exclude any category of property where the total appraised value of all property in that category is 

less than $2,000.

Item 18 All appraisals that have been prepared for real property listed in Item 18.

Item 21 Documentation for all debts listed in Item 21.

Item 22 All executed documents for any trust or escrow listed in Item 22. Also provide any appraisals, including insurance 

appraisals that have been done for any assets held by any such trust or in any such escrow. 

SUMMARY FINANCIAL SCHEDULES

Item 25. Combined Balance Sheet for You, Your Spouse, and Your Dependents

Assets Liabilities

Cash on Hand (Item 9) $ Loans Against Publicly Traded Securities (Item 10) $

Funds Held in Financial Institutions (Item 9) $ Vehicles - Liens (Item 16) $

U.S. Government Securities (Item 10) $ Real Property – Encumbrances (Item 18) $

Publicly Traded Securities (Item 10) $ Credit Cards (Item 19) $

Non-Public Business and Financial Interests (Item 11) $ Taxes Payable (Item 20) $

Amounts Owed to You (Item 12) $ Amounts Owed by You (Item 21) $

Life Insurance Policies (Item 13) $ Other Liabilities (Itemize)

Deferred Income Arrangements (Item 14) $ $

Vehicles (Item 16) $ $

Other Personal Property (Item 17) $ $

Real Property (Item 18) $ $

Other Assets (Itemize) $

$ $

$ $

$ $

Total Assets $ Total Liabilities $

Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents

Provide the current monthly income and expenses for you, your spouse, and your dependents. Do not include credit card payments separately; rather, 

include credit card expenditures in the appropriate categories.

Income (State source of each item) Expenses

Salary - After Taxes

Source: $ Mortgage or Rental Payments for Residence(s) $ 

Fees, Commissions, and Royalties

Source: $ Property Taxes for Residence(s) $ 

Interest

Source: $ Rental Property Expenses, Including Mortgage Payments, Taxes, 

and Insurance $ 

Dividends and Capital Gains

Source: $ Car or Other Vehicle Lease or Loan Payments $ 

Gross Rental Income

Source: $ Food Expenses $ 

Profits from Sole Proprietorships

Source: $ Clothing Expenses $ 

Distributions from Partnerships, S-Corporations, 

and LLCs

Source:

$ 

Utilities

$ 

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 10 of 10 Federal Trade Commission Financial Statement of Individual Defendant

Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents (cont.)

Distributions from Trusts and Estates

Source: $ Medical Expenses, Including Insurance $ 

Distributions from Deferred Income Arrangements 

Source: $ Other Insurance Premiums

$ 

Social Security Payments $ Other Transportation Expenses $

Alimony/Child Support Received $ Other Expenses (Itemize)

Gambling Income $ $

Other Income (Itemize) $

$ $

$ $

$ $

Total Income $ Total Expenses $ 

ATTACHMENTS

Item 27. Documents Attached to this Financial Statement List all documents that are being submitted with this financial statement. For any Item 24 documents that are not attached, explain why.

Item No. Document Relates To Description of Document

I am submitting this financial statement with the understanding that it may affect action by the Federal Trade

Commission or a federal court. I have used my best efforts to obtain the information requested in this statement. The 

responses I have provided to the items above are true and contain all the requested facts and information of which I have 

notice or knowledge. I have provided all requested documents in my custody, possession, or control. I know of the 

penalties for false statements under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 18 U.S.C. § 1623 (five years imprisonment 

and/or fines). I certify under penalty of perjury under the laws of the United States that the foregoing is true and correct. 

Executed on:

_______________ ___________________________________

(Date) Signature
FEDERAL TRADE COMMISSION

FINANCIAL STATEMENT OF CORPORATE DEFENDANT

Instructions:

1. Complete all items. Enter “None” or "N/A" (“Not Applicable”) where appropriate. If you cannot fully answer a

question, explain why.

2. The font size within each field will adjust automatically as you type to accommodate longer responses.

3. In completing this financial statement, “the corporation” refers not only to this corporation but also to each of its

predecessors that are not named defendants in this action.

4. When an Item asks for information about assets or liabilities “held by the corporation,” include ALL such assets

and liabilities, located within the United States or elsewhere, held by the corporation or held by others for the

benefit of the corporation.

5. Attach continuation pages as needed. On the financial statement, state next to the Item number that the Item is

being continued. On the continuation page(s), identify the Item number being continued. 

6. Type or print legibly. 

7. An officer of the corporation must sign and date the completed financial statement on the last page and initial

each page in the space provided in the lower right corner. 

Penalty for False Information:

Federal law provides that any person may be imprisoned for not more than five years, fined, or both, if such person:

(1) “in any matter within the jurisdiction of any department or agency of the United States knowingly and

willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false,

fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the

same to contain any false, fictitious or fraudulent statement or entry” (18 U.S.C. § 1001);

(2) “in any . . . statement under penalty of perjury as permitted under section 1746 of title 28, United States Code,

willfully subscribes as true any material matter which he does not believe to be true” (18 U.S.C. § 1621); or

(3) “in any (. . . statement under penalty of perjury as permitted under section 1746 of title 28, United States

Code) in any proceeding before or ancillary to any court or grand jury of the United States knowingly makes any

false material declaration or makes or uses any other information . . . knowing the same to contain any false

material declaration.” (18 U.S.C. § 1623)

For a felony conviction under the provisions cited above, federal law provides that the fine may be not more than the

greater of (i) $250,000 for an individual or $500,000 for a corporation, or (ii) if the felony results in pecuniary gain to any

person or pecuniary loss to any person other than the defendant, the greater of twice the gross gain or twice the gross loss.

18 U.S.C. § 3571.
Page 2 Initials __________

BACKGROUND INFORMATION

Item 1. General Information 

Corporation’s Full Name ___________________________________________________________________________

Primary Business Address ______________________________________________________ From (Date) _________

Telephone No. _____________________________ Fax No. _____________________________

 E-Mail Address________________________ Internet Home Page________________________

All other current addresses & previous addresses for past five years, including post office boxes and mail drops: 

Address____________________________________________________________ From/Until____________________

Address____________________________________________________________ From/Until____________________

Address____________________________________________________________ From/Until____________________

All predecessor companies for past five years:

Name & Address _________________________________________________________ From/Until ______________

Name & Address _________________________________________________________ From/Until ______________

Name & Address _________________________________________________________ From/Until ______________

Item 2. Legal Information 

Federal Taxpayer ID No. _________________________ State & Date of Incorporation _________________________

State Tax ID No. ____________________ State ________________ Profit or Not For Profit _____________________

Corporation’s Present Status: Active ________________ Inactive _______________ Dissolved __________________

If Dissolved: Date dissolved _________________________ By Whom ______________________________________

Reasons _________________________________________________________________________________________

Fiscal Year-End (Mo./Day) ________________ Corporation’s Business Activities _____________________________

Item 3. Registered Agent

Name of Registered Agent __________________________________________________________________________

Address __________________________________________________________ Telephone No. __________________
Page 3 Initials __________

Item 4. Principal Stockholders

List all persons and entities that own at least 5% of the corporation’s stock.

Name & Address % Owned

_________________________________________________________________________________ ______________

_________________________________________________________________________________ ______________

_________________________________________________________________________________ ______________

_________________________________________________________________________________ ______________

Item 5. Board Members 

List all members of the corporation’s Board of Directors. 

Name & Address % Owned Term (From/Until)

____________________________________________________________________ __________ _________________

____________________________________________________________________ __________ _________________

____________________________________________________________________ __________ _________________

____________________________________________________________________ __________ _________________

____________________________________________________________________ __________ _________________

Item 6. Officers

List all of the corporation’s officers, including de facto officers (individuals with significant management responsibility

whose titles do not reflect the nature of their positions).

Name & Address % Owned

_______________________________________________________________________________ ________________

_______________________________________________________________________________ ________________

_______________________________________________________________________________ ________________

_______________________________________________________________________________ ________________

_______________________________________________________________________________ ________________
Page 4 Initials __________

Item 7. Businesses Related to the Corporation 

List all corporations, partnerships, and other business entities in which this corporation has an ownership interest.

Name & Address Business Activities % Owned 

___________________________________________________________________ ___________________ _________

___________________________________________________________________ ___________________ _________

___________________________________________________________________ ___________________ _________

State which of these businesses, if any, has ever transacted business with the corporation _______________________

________________________________________________________________________________________________

Item 8. Businesses Related to Individuals

List all corporations, partnerships, and other business entities in which the corporation’s principal stockholders, board

members, or officers (i.e., the individuals listed in Items 4 - 6 above) have an ownership interest. 

Individual’s Name Business Name & Address Business Activities % Owned

__________________ __________________________________________________ __________________ ________

__________________ __________________________________________________ __________________ ________

__________________ __________________________________________________ __________________ ________

State which of these businesses, if any, have ever transacted business with the corporation _______________________

________________________________________________________________________________________________

Item 9. Related Individuals

List all related individuals with whom the corporation has had any business transactions during the three previous fiscal

years and current fiscal year-to-date. A “related individual” is a spouse, sibling, parent, or child of the principal

stockholders, board members, and officers (i.e., the individuals listed in Items 4 - 6 above).

Name and Address Relationship Business Activities

_________________________________________________________ _________________ ______________________

_________________________________________________________ _________________ ______________________

_________________________________________________________ _________________ ______________________
Page 5 Initials __________

Item 10. Outside Accountants

List all outside accountants retained by the corporation during the last three years.

Name Firm Name Address CPA/PA?

____________________ ______________________ ________________________________________ ____________

____________________ ______________________ ________________________________________ ____________

____________________ ______________________ ________________________________________ ____________

____________________ ______________________ ________________________________________ ____________

____________________ ______________________ ________________________________________ ____________

Item 11. Corporation’s Recordkeeping

List all individuals within the corporation with responsibility for keeping the corporation’s financial books and records for

the last three years. 

Name, Address, & Telephone Number Position(s) Held

____________________________________________________________________________ ___________________

____________________________________________________________________________ ___________________

____________________________________________________________________________ ___________________

____________________________________________________________________________ ___________________

Item 12. Attorneys

List all attorneys retained by the corporation during the last three years.

Name Firm Name Address

____________________ ___________________________ ________________________________________________

____________________ ___________________________ ________________________________________________

____________________ ___________________________ ________________________________________________

____________________ ___________________________ ________________________________________________

____________________ ___________________________ ________________________________________________
Page 6 Initials __________

Item 13. Pending Lawsuits Filed by the Corporation 

List all pending lawsuits that have been filed by the corporation in court or before an administrative agency. (List

lawsuits that resulted in final judgments or settlements in favor of the corporation in Item 25). 

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________
Page 7 Initials __________

Item 14. Current Lawsuits Filed Against the Corporation 

List all pending lawsuits that have been filed against the corporation in court or before an administrative agency. (List

lawsuits that resulted in final judgments, settlements, or orders in Items 26 - 27).

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address___________________________________________________________________________

Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________

____________________________________ Status______________________________________________________
Page 8 Initials __________

Item 15. Bankruptcy Information

List all state insolvency and federal bankruptcy proceedings involving the corporation. 

Commencement Date _________________ Termination Date _________________ Docket No. __________________

If State Court: Court & County _______________________ If Federal Court: District __________________________

Disposition ______________________________________________________________________________________

Item 16. Safe Deposit Boxes

List all safe deposit boxes, located within the United States or elsewhere, held by the corporation, or held by others for the

benefit of the corporation. On a separate page, describe the contents of each box.

Owner’s Name Name & Address of Depository Institution Box No.

__________________ ___________________________________________________________________ __________

__________________ ___________________________________________________________________ __________

__________________ ___________________________________________________________________ __________

__________________ ___________________________________________________________________ __________

__________________ ___________________________________________________________________ __________

FINANCIAL INFORMATION

REMINDER: When an Item asks for information about assets or liabilities “held by the corporation,” include

ALL such assets and liabilities, located within the United States or elsewhere, held by the corporation or held by

others for the benefit of the corporation.

Item 17. Tax Returns

List all federal and state corporate tax returns filed for the last three complete fiscal years. Attach copies of all returns.

Federal/

State/Both

Tax Year Tax Due

Federal

Tax Paid

Federal

Tax Due

State

Tax Paid

State

Preparer’s Name

___________ __________ $_________ $_________ $__________ $__________ ______________________________

___________ __________ $_________ $_________ $__________ $__________ ______________________________

___________ __________ $_________ $_________ $__________ $__________ ______________________________
Page 9 Initials __________

Item 18. Financial Statements

List all financial statements that were prepared for the corporation’s last three complete fiscal years and for the current

fiscal year-to-date. Attach copies of all statements, providing audited statements if available.

Year Balance Sheet Profit & Loss Statement Cash Flow Statement Changes in Owner’s Equity Audited?

_________ _____________ ______________________ __________________ _______________________ ________

_________ _____________ ______________________ __________________ _______________________ ________

_________ _____________ ______________________ __________________ _______________________ ________

_________ _____________ ______________________ __________________ _______________________ ________

Item 19. Financial Summary

For each of the last three complete fiscal years and for the current fiscal year-to-date for which the corporation has not

provided a profit and loss statement in accordance with Item 18 above, provide the following summary financial

information.

Current Year-to-Date 1 Year Ago 2 Years Ago 3 Years Ago

Gross Revenue $_________________ $_______________ $_______________ $_______________

Expenses $_________________ $_______________ $_______________ $_______________

Net Profit After Taxes $_________________ $_______________ $_______________ $_______________

Payables $_________________

Receivables $_________________

Item 20. Cash, Bank, and Money Market Accounts 

List cash and all bank and money market accounts, including but not limited to, checking accounts, savings accounts, and

certificates of deposit, held by the corporation. The term “cash” includes currency and uncashed checks. 

Cash on Hand $_________________________ Cash Held for the Corporation’s Benefit $_______________________

Name & Address of Financial Institution Signator(s) on Account Account No. Current

Balance

_____________________________________ _______________________________ ______________ $___________

_____________________________________ _______________________________ ______________ $___________

_____________________________________ _______________________________ ______________ $___________

_____________________________________ _______________________________ ______________ $___________
Page 10 Initials __________

Item 21. Government Obligations and Publicly Traded Securities 

List all U.S. Government obligations, including but not limited to, savings bonds, treasury bills, or treasury notes, held by

the corporation. Also list all publicly traded securities, including but not limited to, stocks, stock options, registered and

bearer bonds, state and municipal bonds, and mutual funds, held by the corporation. 

Issuer _________________________________ Type of Security/Obligation __________________________________

No. of Units Owned __________ Current Fair Market Value $__________________ Maturity Date _______________

Issuer _________________________________ Type of Security/Obligation __________________________________

No. of Units Owned __________ Current Fair Market Value $__________________ Maturity Date _______________

Item 22. Real Estate 

List all real estate, including leaseholds in excess of five years, held by the corporation. 

Type of Property________________________________ Property’s Location__________________________________

Name(s) on Title and Ownership Percentages___________________________________________________________

Current Value $____________________ Loan or Account No. __________________________

Lender’s Name and Address_________________________________________________________________________

Current Balance On First Mortgage $_______________ Monthly Payment $______________

Other Loan(s) (describe)____________________________________________ Current Balance $_________________

Monthly Payment $__________________ Rental Unit?_________________ Monthly Rent Received $_____________

Type of Property________________________________ Property’s Location__________________________________

Name(s) on Title and Ownership Percentages___________________________________________________________

Current Value $____________________ Loan or Account No. __________________________

Lender’s Name and Address_________________________________________________________________________

Current Balance On First Mortgage $_______________ Monthly Payment $______________

Other Loan(s) (describe)____________________________________________ Current Balance $_________________

Monthly Payment $__________________ Rental Unit?_________________ Monthly Rent Received $_____________
Page 11 Initials __________

Item 23. Other Assets 

List all other property, by category, with an estimated value of $2,500 or more, held by the corporation, including but not

limited to, inventory, machinery, equipment, furniture, vehicles, customer lists, computer software, patents, and other

intellectual property. 

Property Category Property Location Acquisition

Cost

Current

Value

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

____________________________ _____________________________________________ $__________ $_________

Item 24. Trusts and Escrows

List all persons and other entities holding funds or other assets that are in escrow or in trust for the corporation.

Trustee or Escrow Agent’s 

Name & Address

Description and Location of Assets Present Market

Value of Assets

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________

______________________________________ _______________________________________ $_________________
Page 12 Initials __________

Item 25. Monetary Judgments and Settlements Owed To the Corporation

List all monetary judgments and settlements, recorded and unrecorded, owed to the corporation.

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________

Item 26. Monetary Judgments and Settlements Owed By the Corporation

List all monetary judgments and settlements, recorded and unrecorded, owed by the corporation. 

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit_______________________________________ Date______________ Amount $______________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________

Opposing Party’s Name & Address___________________________________________________________________

Court’s Name & Address____________________________________________________ Docket No._____________

Nature of Lawsuit______________________________ Date of Judgment________________ Amount $____________
Page 13 Initials __________

Item 27. Government Orders and Settlements 

List all existing orders and settlements between the corporation and any federal or state government entities.

Name of Agency ___________________________________________ Contact Person __________________________

Address _____________________________________________________________ Telephone No. _______________ 

Agreement Date ______________ Nature of Agreement __________________________________________________

Item 28. Credit Cards

List all of the corporation’s credit cards and store charge accounts and the individuals authorized to use them. 

Name of Credit Card or Store Names of Authorized Users and Positions Held

__________________________________________ _____________________________________________________

__________________________________________ _____________________________________________________

__________________________________________ _____________________________________________________

__________________________________________ _____________________________________________________

__________________________________________ _____________________________________________________

Item 29. Compensation of Employees

List all compensation and other benefits received from the corporation by the five most highly compensated employees,

independent contractors, and consultants (other than those individuals listed in Items 5 and 6 above), for the two previous

fiscal years and current fiscal year-to-date. “Compensation” includes, but is not limited to, salaries, commissions,

consulting fees, bonuses, dividends, distributions, royalties, pensions, and profit sharing plans. “Other benefits” include,

but are not limited to, loans, loan payments, rent, car payments, and insurance premiums, whether paid directly to the

individuals, or paid to others on their behalf.

Name/Position Current Fiscal

Year-to-Date

1 Year Ago 2 Years Ago Compensation or 

Type of Benefits

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________
Page 14 Initials __________

Item 30. Compensation of Board Members and Officers 

List all compensation and other benefits received from the corporation by each person listed in Items 5 and 6, for the

current fiscal year-to-date and the two previous fiscal years. “Compensation” includes, but is not limited to, salaries,

commissions, consulting fees, dividends, distributions, royalties, pensions, and profit sharing plans. “Other benefits”

include, but are not limited to, loans, loan payments, rent, car payments, and insurance premiums, whether paid directly to

the individuals, or paid to others on their behalf.

Name/Position Current Fiscal

Year-to-Date

1 Year Ago 2 Years Ago Compensation or 

Type of Benefits

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

_____________________________ $____________ $___________ $____________ ___________________________

Item 31. Transfers of Assets Including Cash and Property

List all transfers of assets over $2,500 made by the corporation, other than in the ordinary course of business, during the

previous three years, by loan, gift, sale, or other transfer. 

Transferee’s Name, Address, & Relationship Property

Transferred

Aggregate

Value

Transfer

Date

Type of Transfer

(e.g., Loan, Gift)

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________
Page 15 Initials __________

Item 32. Documents Attached to the Financial Statement

List all documents that are being submitted with the financial statement.

Item No. Document

Relates To

Description of Document

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

___________________ ____________________________________________________________________________

I am submitting this financial statement with the understanding that it may affect action by the Federal Trade

Commission or a federal court. I have used my best efforts to obtain the information requested in this statement. The

responses I have provided to the items above are true and contain all the requested facts and information of which I have

notice or knowledge. I have provided all requested documents in my custody, possession, or control. I know of the

penalties for false statements under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 18 U.S.C. § 1623 (five years imprisonment

and/or fines). I certify under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Executed on:

______________________________ _____________________________________________________

(Date) Signature

_____________________________________________________

Corporate Position
Form 4506

(July 2017)

Department of the Treasury 

Internal Revenue Service 

Request for Copy of Tax Return

a Do not sign this form unless all applicable lines have been completed.

a Request may be rejected if the form is incomplete or illegible. 

a For more information about Form 4506, visit www.irs.gov/form4506.

OMB No. 1545-0429

Tip. You may be able to get your tax return or return information from other sources. If you had your tax return completed by a paid preparer, they 

should be able to provide you a copy of the return. The IRS can provide a Tax Return Transcript for many returns free of charge. The transcript 

provides most of the line entries from the original tax return and usually contains the information that a third party (such as a mortgage company) 

requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated self-help service 

tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” or call 1-800-908-9946.

1a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number on tax return, 

individual taxpayer identification number, or 

employer identification number (see instructions) 

2a If a joint return, enter spouse’s name shown on tax return. 2b Second social security number or individual 

taxpayer identification number if joint tax return 

3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions) 

4 Previous address shown on the last return filed if different from line 3 (see instructions) 

5 If the tax return is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number. 

Caution: If the tax return is being mailed to a third party, ensure that you have filled in lines 6 and 7 before signing. Sign and date the form once you 

have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line 

5, the IRS has no control over what the third party does with the information. If you would like to limit the third party's authority to disclose your return 

information, you can specify this limitation in your written agreement with the third party.

6 Tax return requested. Form 1040, 1120, 941, etc. and all attachments as originally submitted to the IRS, including Form(s) W-2, 

schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are 

destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one 

type of return, you must complete another Form 4506. a

Note: If the copies must be certified for court or administrative proceedings, check here ...............

7 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than 

eight years or periods, you must attach another Form 4506. 

8 Fee. There is a $50 fee for each return requested. Full payment must be included with your request or it will 

be rejected. Make your check or money order payable to “United States Treasury.” Enter your SSN, ITIN, 

or EIN and “Form 4506 request” on your check or money order. 

a Cost for each return ........................... $ 

b Number of returns requested on line 7 ......................

c Total cost. Multiply line 8a by line 8b ...................... $ 

9 If we cannot find the tax return, we will refund the fee. If the refund should go to the third party listed on line 5, check here . . . . .

Caution: Do not sign this form unless all applicable lines have been completed. 

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax return 

requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, 

managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to 

execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.

Signatory attests that he/she has read the attestation clause and upon so reading 

declares that he/she has the authority to sign the Form 4506. See instructions. 

Sign 

Here 

Phone number of taxpayer on line 

1a or 2a 

F

Signature (see instructions) Date 

F

Title (if line 1a above is a corporation, partnership, estate, or trust) 

F

Spouse’s signature Date 

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721E Form 4506 (Rev. 7-2017) 

50.00
Form 4506 (Rev. 7-2017) Page 2 

Section references are to the Internal Revenue Code 

unless otherwise noted. 

Future Developments

For the latest information about Form 4506 and its 

instructions, go to www.irs.gov/form4506. 

Information about any recent developments affecting 

Form 4506, Form 4506-T and Form 4506T-EZ will be 

posted on that page. 

General Instructions 

Caution: Do not sign this form unless all applicable 

lines have been completed.

Purpose of form. Use Form 4506 to request a copy 

of your tax return. You can also designate (on line 5) 

a third party to receive the tax return. 

How long will it take? It may take up to 75 

calendar days for us to process your request. 

Tip. Use Form 4506-T, Request for Transcript of Tax 

Return, to request tax return transcripts, tax account 

information, W-2 information, 1099 information, 

verification of nonfiling, and records of account. 

Automated transcript request. You can quickly 

request transcripts by using our automated self-help 

service tools. Please visit us at IRS.gov and click on 

“Get a Tax Transcript...” or call 1-800-908-9946. 

Where to file. Attach payment and mail Form 4506 

to the address below for the state you lived in, or the 

state your business was in, when that return was 

filed. There are two address charts: one for 

individual returns (Form 1040 series) and one for all 

other returns. 

If you are requesting a return for more than one 

year or period and the chart below shows two 

different addresses, send your request to the 

address based on the address of your most recent 

return. 

Chart for individual returns 

(Form 1040 series) 

If you filed an 

individual return 

and lived in: 

Mail to: 

Alabama, Kentucky, 

Louisiana, Mississippi, 

Tennessee, Texas, a 

foreign country, American 

Samoa, Puerto Rico, 

Guam, the 

Commonwealth of the 

Northern Mariana Islands, 

the U.S. Virgin Islands, or 

A.P.O. or F.P.O. address 

Internal Revenue Service 

RAIVS Team 

Stop 6716 AUSC 

Austin, TX 73301 

Alaska, Arizona, 

Arkansas, California, 

Colorado, Hawaii, Idaho, 

Illinois, Indiana, Iowa, 

Kansas, Michigan, 

Minnesota, Montana, 

Nebraska, Nevada, New 

Mexico, North Dakota, 

Oklahoma, Oregon, 

South Dakota, Utah, 

Washington, Wisconsin, 

Wyoming 

Internal Revenue Service 

RAIVS Team 

Stop 37106 

Fresno, CA 93888 

Connecticut, 

Delaware, District of 

Columbia, Florida, 

Georgia, Maine, 

Maryland, 

Massachusetts, 

Missouri, New 

Hampshire, New Jersey, 

New York, North 

Carolina, Ohio, 

Pennsylvania, Rhode 

Island, South Carolina, 

Vermont, Virginia, West 

Virginia 

Internal Revenue Service 

RAIVS Team 

Stop 6705 P-6 

Kansas City, MO 

64999

Chart for all other returns 

If you lived in 

or your business 

was in: 

Mail to: 

Alabama, Alaska, 

Arizona, Arkansas, 

California, Colorado, 

Florida, Hawaii, Idaho, 

Iowa, Kansas, Louisiana, 

Minnesota, Mississippi, 

Missouri, Montana, 

Nebraska, Nevada, 

New Mexico, 

North Dakota, 

Oklahoma, Oregon, 

South Dakota, Texas, 

Utah, Washington, 

Wyoming, a foreign 

country, American 

Samoa, Puerto Rico, 

Guam, the 

Commonwealth of the 

Northern Mariana 

Islands, the U.S. Virgin 

Islands, or A.P.O. or 

F.P.O. address 

Internal Revenue Service 

RAIVS Team 

P.O. Box 9941 

Mail Stop 6734 

Ogden, UT 84409 

Connecticut, Delaware, 

District of Columbia, 

Georgia, Illinois, Indiana, 

Kentucky, Maine, 

Maryland, 

Massachusetts, 

Michigan, New 

Hampshire, New Jersey, 

New York, North 

Carolina, 

Ohio, Pennsylvania, 

Rhode Island, South 

Carolina, Tennessee, 

Vermont, Virginia, West 

Virginia, Wisconsin 

Internal Revenue Service 

RAIVS Team 

P.O. Box 145500 

Stop 2800 F 

Cincinnati, OH 45250 

Specific Instructions 

Line 1b. Enter your employer identification number 

(EIN) if you are requesting a copy of a business 

return. Otherwise, enter the first social security 

number (SSN) or your individual taxpayer 

identification number (ITIN) shown on the return. For 

example, if you are requesting Form 1040 that 

includes Schedule C (Form 1040), enter your SSN. 

Line 3. Enter your current address. If you use a P.O. 

box, please include it on this line 3.

Line 4. Enter the address shown on the last return 

filed if different from the address entered on line 3. 

Note: If the addresses on lines 3 and 4 are different 

and you have not changed your address with the 

IRS, file Form 8822, Change of Address. For a 

business address, file Form 8822-B, Change of 

Address or Responsible Party — Business.

Signature and date. Form 4506 must be signed and 

dated by the taxpayer listed on line 1a or 2a. The 

IRS must receive Form 4506 within 120 days of the 

date signed by the taxpayer or it will be rejected. 

Ensure that all applicable lines are completed before 

signing. 

F!

CAUTION

You must check the box in the 

signature area to acknowledge you 

have the authority to sign and request 

the information. The form will not be 

processed and returned to you if the box is 

unchecked.

Individuals. Copies of jointly filed tax returns may 

be furnished to either spouse. Only one signature is 

required. Sign Form 4506 exactly as your name 

appeared on the original return. If you changed your 

name, also sign your current name. 

Corporations. Generally, Form 4506 can be 

signed by: (1) an officer having legal authority to bind 

the corporation, (2) any person designated by the 

board of directors or other governing body, or (3) 

any officer or employee on written request by any 

principal officer and attested to by the secretary or 

other officer. A bona fide shareholder of record 

owning 1 percent or more of the outstanding stock 

of the corporation may submit a Form 4506 but must 

provide documentation to support the requester's 

right to receive the information.

Partnerships. Generally, Form 4506 can be 

signed by any person who was a member of the 

partnership during any part of the tax period 

requested on line 7. 

All others. See section 6103(e) if the taxpayer has 

died, is insolvent, is a dissolved corporation, or if a 

trustee, guardian, executor, receiver, or 

administrator is acting for the taxpayer. 

Note: If you are Heir at law, Next of kin, or 

Beneficiary you must be able to establish a material 

interest in the estate or trust.

Documentation. For entities other than individuals, 

you must attach the authorization document. For 

example, this could be the letter from the principal 

officer authorizing an employee of the corporation or 

the letters testamentary authorizing an individual to 

act for an estate. 

Signature by a representative. A representative 

can sign Form 4506 for a taxpayer only if this 

authority has been specifically delegated to the 

representative on Form 2848, line 5. Form 2848 

showing the delegation must be attached to Form 

4506. 

Privacy Act and Paperwork Reduction Act 

Notice. We ask for the information on this form to 

establish your right to gain access to the requested 

return(s) under the Internal Revenue Code. We need 

this information to properly identify the return(s) and 

respond to your request. If you request a copy of a 

tax return, sections 6103 and 6109 require you to 

provide this information, including your SSN or EIN, 

to process your request. If you do not provide this 

information, we may not be able to process your 

request. Providing false or fraudulent information 

may subject you to penalties. 

Routine uses of this information include giving it to 

the Department of Justice for civil and criminal 

litigation, and cities, states, the District of Columbia, 

and U.S. commonwealths and possessions for use 

in administering their tax laws. We may also 

disclose this information to other countries under a 

tax treaty, to federal and state agencies to enforce 

federal nontax criminal laws, or to federal law 

enforcement and intelligence agencies to combat 

terrorism. 

You are not required to provide the information 

requested on a form that is subject to the Paperwork 

Reduction Act unless the form displays a valid OMB 

control number. Books or records relating to a form 

or its instructions must be retained as long as their 

contents may become material in the administration 

of any Internal Revenue law. Generally, tax returns 

and return information are confidential, as required 

by section 6103. 

The time needed to complete and file Form 4506 

will vary depending on individual circumstances. The 

estimated average time is: Learning about the law 

or the form, 10 min.; Preparing the form, 16 min.; 

and Copying, assembling, and sending the form 

to the IRS, 20 min. 

If you have comments concerning the accuracy of 

these time estimates or suggestions for making 

Form 4506 simpler, we would be happy to hear from 

you. You can write to: 

Internal Revenue Service 

Tax Forms and Publications Division 

1111 Constitution Ave. NW, IR-6526 

Washington, DC 20224. 

Do not send the form to this address. Instead, see 

Where to file on this page. 
CONSENT TO RELEASE FINANCIAL RECORDS 

 I, __________________________of _______________________, (City, 

State), do hereby direct any bank, saving and loan association, credit union, 

depository institution, finance company, commercial lending company, credit card 

processor, credit card processing entity, automated clearing house, network 

transaction processor, bank debit processing entity, automated clearing house, 

network transaction processor, bank debit processing entity, brokerage house, 

escrow agent, money market or mutual fund, title company, commodity trading 

company, trustee, or person that holds, controls, or maintains custody of assets, 

wherever located, that are owned or controlled by me or at which there is an 

account of any kind upon which I am authorized to draw, and its officers, 

employees, and agents, to disclose all information and deliver copies of all 

documents of every nature in its possession or control which relate to the said 

accounts to any attorney of the Federal Trade Commission, and to give evidence 

relevant thereto, in the matter of [ ], now pending in the United States 

District Court of [ ], and this shall be irrevocable authority for so doing. 

 This direction is intended to apply to the laws of countries other than the 

United States of America which restrict or prohibit disclosure of bank or other 

financial information without the consent of the holder of the account, and shall be 

construed as consent with respect hereto, and the same shall apply to any of the 

accounts for which I may be a relevant principal. 

Dated:_______________ Signature:_____________________________ 

 Printed Name:__________________________