Form 13657 - Notice Of Election By Corporation To Participate In Announcement 2005-19 Settlement Initiative

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Department of the Treasury — Internal Revenue Service
13657
Notice of Election by Corporation to Participate in
Form
(March 2005)
Announcement 2005-19 Settlement Initiative
NOTE:
The Service can decline to execute a closing agreement with any party that fails to provide all
information requested within this Form 13657.
Section I.
Corporation Information
1.
Corporation name
2.
Corporation identification
number
(EIN)
3.
Address
(Street, City, State, ZIP code)
4.
Name and title of person to contact at corporation
5.
Daytime telephone number
(
)
6.
FAX number
(
)
7.
Corporation currently is in Appeals or Examination
Yes
No
(Please complete items 8 and 9.)
8.
Name and address
of Appeals Officer or Agent
9.
Daytime telephone number
(Street, City, State, ZIP code)
(
)
10.
Corporation has executed a Power of Attorney
Yes
No
(Please attach a copy.)
11.
Name of corporation
that received the services from the Executives named in Section III,
12.
Identification number
for
(s)
(EIN)
if different from corporation named in Item 1.
Item 11 entries
(Attach additional sheets, if necessary.)
13.
Did the Corporation file as part of a consolidated federal income tax
Yes
No
(See Items 14 & 15 or Items 16 & 17,
return for any taxable period affected by the terms of the settlement?
whichever is applicable.)
15.
Employer identification number
14.
Name of the Corporation's parent that participated in the transaction
(if the Corporation is a
for Item 14 entry
subsidiary)
(EIN)
16.
Name of the Corporation's subsidiary that participated in the transaction
17. Employer identification number
(if the Corporation
is the parent)
for Item 16 entry
(EIN)
Corporation Attestation
The following Corporation elects to participate in the settlement initiative as described in Announcement 2005-19
and as contained in Internal Revenue Bulletin 2005-11 dated March 14, 2005. The Corporation is submitting with
this election the information and documents requested. Under penalties of perjury, I declare that I have
examined this Form 13657 and to the best of my knowledge and belief, it is true, correct and complete.
Name of authorized Corporate Representative
Corporation name
Title
By
Date
(Signature of authorized Corporate Representative)
Catalog No. 39566V
Sheet 1 of 3
13657
Form
(3-2005)

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