Settlement Initiative Transactions Elected by Taxpayer
(For each box checked below, complete a separate Form 13750, Schedule A and attach it to your election)
10. Have you received a Statutory Notice of Deficiency
11. Has the TEFRA Partnership received a Notice of Final Partnership Administrative Adjustment
12. Do you have a Power of Attorney (If Yes, attach a copy to this election)
13. Have you filed an amended return(s) for any of the years in which you engaged in
this transaction(s) (If Yes, attach a copy or copies to this election)
Department of the Treasury — Internal Revenue Service
Election to Participate in Announcement 2005-80
Settlement Initiative
You must provide all the information required under this Election by January 23, 2006 (or as otherwise
stipulated in subsequent requests from the Service for additional information) to be eligible for the settlement.
Taxpayer Data
Section I
I elect to participate in the settlement initiative as described in Announcement 2005-80 and as contained in Internal
Revenue Bulletin 2005-46 dated November 14, 2005.
1. Taxpayer name(s) (Include name of spouse if joint return)
2. Taxpayer(s) Identification
Number (EIN or SSN)
6. Are you currently under examination or in Appeals
7. Are/were you (or your spouse) a partner in a TEFRA partnership
that was a party to the arrangement(s) identified in Section II
Yes
No (Please provide copies of all relevant tax
returns with your election submission)
Yes (Please complete items 8a and 8b)
No
No
No
Yes
No
Section II
Catalog No. 47521K
Form 13750 (10-2005)
www.irs.gov
Note
3. Address (Street, City, State, ZIP code)
4. Telephone number
( )
Yes (Complete items 9a & 9b and Section III)
8a. Name and address (Street, City, State, ZIP Code) of
IRS contact for your current examination or Appeals
matter (If applicable)
9a. Name and address (Street, City, State, ZIP Code) of
IRS contact for the TEFRA Partnership examination
or Appeals matter (If applicable)
Notice 2002-21 (20%