Form 1120-SF

(Rev. December 2016)

Department of the Treasury 

Internal Revenue Service

U.S. Income Tax Return for Settlement Funds 

(Under Section 468B)

▶ Information about Form 1120-SF and its separate instructions is at www.irs.gov/form1120sf.

For calendar year 20

OMB No. 1545-0123

Please Type or Print

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 or province, country, and ZIP or foreign postal code

Name and address of administrator (see instructions for definition) 

Check applicable boxes: (1) Final return (2) Name change (3) Address change (4) Amended return

Part I Income and Deductions (see instructions) Income

1 Taxable interest . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Capital gain net income (attach Schedule D (Form 1120)) . . . . . . . . . . . 3

4 Items of income or gain from a partnership interest . . . . . . . . . . . . . 4

5 Other income (attach schedule) . . . . . . . . . . . . . . . . . . . 5

6 Gross income. Add lines 1 through 5 . . . . . . . . . . . . . . . . . 6

Deductions

7 Trustee/administrator fees . . . . . . . . . . . . . . . . . . . . . 7

8 Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Accounting and legal services (attach schedule) . . . . . . . . . . . . . . 9

10 Notification of claimants and claim processing expenses . . . . . . . . . . . 10

11 Other deductions (attach schedule) . . . . . . . . . . . . . . . . . . 11

12 Net operating loss deduction . . . . . . . . . . . . . . . . . . . . 12

13 Total deductions. Add lines 7 through 12 . . . . . . . . . . . . . . . . 13

Part II Tax Computation (see instructions) 

14 Modified gross income. Subtract line 13 from line 6 . . . . . . . . . . . . 14

15 Total tax. Multiply the amount on line 14 by 39.6% (0.396) . . . . . . . . . . 15

16 Credits and payments:

a Overpayment from prior year allowed as 

a credit . . . . . . . . . . . 16a

b Current year estimated tax payments . 16b

c Refund of overpaid estimated tax 

applied for on Form 4466 . . . . . 16c

d Subtract line 16c from the total of lines 16a and 16b . . . . 16d

e Tax deposited with Form 7004 . . . . . . . . . . . 16e

f Total credits and payments (add lines 16d and 16e) . . . . . . . . . . . . . 16f

17 Estimated tax penalty (see instructions). Check if Form 2220 is attached . . . . . ▶ 17

18 Tax due. If the total of lines 15 and 17 is more than line 16f, enter amount owed . . . 18

19 Overpayment. If line 16f is more than the total of lines 15 and 17, enter amount overpaid 19

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

Refunded ▶ . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Sign 

Here

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.

▲

Signature of fund administrator Date ▲

Title

May the IRS discuss this return 

with the preparer shown below? 

See instructions. Yes No

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if 

self-employed 

PTIN

Firm’s name ▶

Firm’s address ▶

Firm’s EIN ▶

Phone no. 

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 14989I Form 1120-SF (Rev. 12-2016) 
Form 1120-SF (Rev. 12-2016) Page 2 

Schedule L Balance Sheets (a) Beginning of year (b) End of year

Assets 

1 Cash . . . . . . . . . . . . . . . . . . . . . 1

2 U.S. Government obligations . . . . . . . . . . . . . 2

3 State and local government obligations . . . . . . . . . . 3

4 Other investments (attach schedule) . . . . . . . . . . . 4

5 Other assets (attach schedule) . . . . . . . . . . . . . 5

6 Total assets. Add lines 1 through 5 . . . . . . . . . . . 6

Liabilities and Fund Balance

7 Liabilities . . . . . . . . . . . . . . . . . . . . 7

8 Fund balance . . . . . . . . . . . . . . . . . . 8

9 Total. Add lines 7 and 8 . . . . . . . . . . . . . . . 9

Additional Information 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 . . . . . . . . . . . . . . . . . . . . . . . . . . .

Form 1120-SF (Rev. 12-2016)