Form 4684 - Casualties And Thefts - 2013 Page 3
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Form 4684 (2013)
Page
Name(s) shown on tax return
Identifying number
SECTION C—Theft Loss Deduction for Ponzi-Type Investment Scheme Using the Procedures in Revenue
Procedure 2009-20 (Complete this section in lieu of Appendix A in Revenue Procedure 2009-20. See instructions.)
Computation of Deduction
Part I
40 Initial investment .
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40
41 Subsequent investments (see instructions) .
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41
42 Income reported on your tax returns for tax years prior to the discovery year
(see instructions) .
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42
43 Add lines 40, 41, and 42
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43
44 Withdrawals for all years (see instructions) .
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44
45 Subtract line 44 from line 43. This is your total qualified investment .
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45
46 Enter .95 (95%) if you have no potential third-party recovery. Enter .75 (75%) if you
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have potential third-party recovery
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46
47 Multiply line 46 by line 45 .
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47
48 Actual recovery .
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48
49 Potential insurance/Securities Investor Protection Corporation (SIPC) recovery
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50 Add lines 48 and 49. This is your total recovery .
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50
51 Subtract line 50 from line 47. This is your deductible theft loss. Include this amount on
line 28. Do not complete lines 19-27 for this loss. Then complete Section B, Part II
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51
Required Statements and Declarations (See instructions.)
Part II
• I am claiming a theft loss deduction pursuant to Revenue Procedure 2009-20 from a specified fraudulent arrangement conducted by the following
individual or entity.
Name of individual or entity
Taxpayer identification number (if known)
Address
• I have written documentation to support the amounts reported in Part I of this Section C.
• I am a qualified investor as defined in section 4.03 of Revenue Procedure 2009-20.
• If I have determined the amount of my theft loss deduction using .95 on line 46 above, I declare that I have not pursued and do not intend to pursue
any potential third-party recovery, as that term is defined in section 4.10 of Revenue Procedure 2009-20.
• I agree to comply with the conditions and agreements set forth in Revenue Procedure 2009-20 and this Section C.
• If I have already filed a return or amended return that does not satisfy the conditions in section 6.02 of Revenue Procedure 2009-20, I agree to all
adjustments or actions that are necessary to comply with those conditions. The tax year(s) for which I filed the return(s) or amended return(s) and the
date(s) on which they were filed are as follows:
4684
Form
(2013)
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