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

(Rev. November 2003) (Under Section 468B) OMB No. 1545-1394

Department of the Treasury

Internal Revenue Service 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)

Please Type or Print

Income and Deductions (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)

11 Other deductions (attach schedule) 11

Deductions

12 12

13

Net operating loss deduction

13

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

Tax Computation (see instructions)

15 Total tax. Enter 35% of line 14 15

16 Credits and payments:

Overpayment from prior year allowed

as a credit

a

16a

b Current year estimated tax payments 16b

Refund of overpaid estimated tax

applied for on Form 4466

c

16c

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

e Tax deposited with Form 7004 16e

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

17 Estimated tax penalty (see page 4 of 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 

20

For Paperwork Reduction Act Notice, see page 4 of separate instructions. Form 1120-SF (Rev. 11-2003)

Part I

Part II

Cat. No. 14989I

9

10 Notification of claimants and claim processing expenses

9

10

Items of income or gain from a partnership interest

Total deductions. Add lines 7 through 12

Refunded 

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

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. Sign

Here

Signature of fund administrator Date Title

Date Preparer’s SSN or PTIN Preparer’s

signature

Check if

self-employed

Paid

Preparer’s

Use Only

Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

Phone no. ( )

May the IRS discuss this return

with the preparer shown below  (see instructions)? Yes No






Form 1120-SF (Rev.11-2003) Page 2

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

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,

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).

Form 1120-SF (Rev. 11-2003)