4684
Casualties and Thefts
OMB No. 1545-0177
2011
Form
See separate instructions.
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Attach to your tax return.
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Attachment
Department of the Treasury
Use a separate Form 4684 for each casualty or theft.
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Internal Revenue Service
Sequence No.
Name(s) shown on tax return
Identifying number
SECTION A—Personal Use Property (Use this section to report casualties and thefts of property not used in a trade
or business or for income-producing purposes.)
1 Description of properties (show type, location, and date acquired for each property). Use a separate line for each property lost or damaged from
the same casualty or theft.
Property A
Property B
Property C
Property D
Properties
A
B
C
D
2 Cost or other basis of each property .
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3 Insurance or other reimbursement (whether or not you
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filed a claim) (see instructions) .
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Note: If line 2 is more than line 3, skip line 4.
4 Gain from casualty or theft. If line 3 is more than line 2,
enter the difference here and skip lines 5 through 9 for
that column. See instructions if line 3 includes insurance
or other reimbursement you did not claim, or you
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received payment for your loss in a later tax year
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5 Fair market value before casualty or theft
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6 Fair market value after casualty or theft .
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7 Subtract line 6 from line 5 .
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8 Enter the smaller of line 2 or line 7
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9 Subtract line 3 from line 8. If zero or less, enter -0- .
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10 Casualty or theft loss. Add the amounts on line 9 in columns A through D .
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11 Enter the smaller of line 10 or $100 .
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12 Subtract line 11 from line 10
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Caution: Use only one Form 4684 for lines 13 through 18.
13 Add the amounts on line 12 of all Forms 4684 .
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14 Add the amounts on line 4 of all Forms 4684.
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15 • If line 14 is more than line 13, enter the difference here and on Schedule D. Do not
complete the rest of this section (see instructions).
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• If line 14 is less than line 13, enter -0- here and go to line 16.
• If line 14 is equal to line 13, enter -0- here. Do not complete the rest of this section.
16 If line 14 is less than line 13, enter the difference .
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17 Enter 10% of your adjusted gross income from Form 1040, line 38, or Form 1040NR, line 37. Estates and trusts, see
instructions
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18 Subtract line 17 from line 16. If zero or less, enter -0-. Also enter the result on Schedule A (Form 1040), line 20, or
Form 1040NR, Schedule A, line 6. Estates and trusts, enter the result on the “Other deductions” line of your tax
return .
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4684
For Paperwork Reduction Act Notice, see instructions.
Form
(2011)
Cat. No. 12997O