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

(Under Section 468B) OMB No. 1545-1394

Expires 8-31-96 (October 1993)

Department of the Treasury

Internal Revenue Service

For tax year beginning , 19 , and ending , 19 .

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 (see instructions)

Please Type or Print

Check applicable boxes: (1) Final return (2) Change of address (3) Amended return

Income and Deductions of Fund (see instructions)

1 Taxable interest 1

2 Dividends 2

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

4

Income

4

5 Other income (attach schedule) 5

6 Gross income. Add lines 1 through 5 6

7 Trustee/administrator fees 7

8 Taxes 8

Accounting and legal services (attach schedule)

12 Other deductions (attach schedule) 12

13 13

Deductions

14

Net operating loss deduction

14

15 Modified gross income. Subtract line 14 from line 5 15

Tax Computation

16 Total tax—Enter 39.6% of line 15 (see instructions) 16

17 Credits and payments:

Overpayment from prior year allowed

as a credit

a

17a

b Current year estimated tax payments 17b

Refund of overpaid estimated tax

applied for on Form 4466

c

17c

d Subtract line 17c from the total of lines 17a and 17b 17d

e Tax deposited with Form 7004 17e

Total credits and payments (add lines 17d and 17e) 17f f

18 Estimated tax penalty (see page 4 of instructions). Check if Form 2220 is attached 18

19 Tax due—If the total of lines 16 and 18 is more than line 17f, enter amount owed 19

20 Overpayment—If line 17f is more than the total of lines 16 and 18, enter amount overpaid 20

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

21

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

Please belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Sign

Here Signature of person filing return Date Title

Check Preparer’s social security number if selfemployed

Date Preparer’s Paid signature

Preparer’s

Use Only Firm’s name (or

yours if self-employed)

and address

E.I. No. ©

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 1120-SF (10-93)

Part I

Part II

©

©

©

©

Cat. No. 14989I

ZIP code ©

11

9

Notification of claimants and claim processing expenses

Items of loss, deduction, or credit from a partnership interest

10

11

9

10

Items of income or gain from a partnership interest

Total deductions. Add lines 7 through 13 

Refunded
Form 1120-SF (10-93) Page 2

Balance Sheets Beginning of year 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

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 $

1a

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).

b

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? ©

5a

Schedule L

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

fund was established

Check the type of liability (or liabilities) for which the fund was established.

If “Yes,” enter the amount of the total distributions $

Tort

Breach of Contract

Violation of Law

CERCLA

Other

6

b

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,

taxpayer identifying number, and the amount of distributions to each transferor or related

party $

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).