4549-E
Return Form No.
Form
Department of the Treasury - Internal Revenue Service
Income Tax Discrepancy Adjustments
(May 1993)
Name and Address of Taxpayers
S.S. or E.I. Number
Filing Status
Person With
Name and Title
Whom
Discrepancy
Adjustments
Were
Discussed
1. Adjustments (our changes) to Income you reported
Year:
Year:
Year:
a.
b.
c.
d.
e.
f.
g.
2. Total Adjustments
3. Adjusted Gross or Taxable Income you showed on your
Return or as Previously Adjusted
4. Adjusted Gross or Taxable Income after our changes
5. Corrected Tax
a.
6. Credits
b.
c.
d. Total of lines 6a, 6b and 6c
7. Balance (Line 5 minus line 6d)
8. Other Taxes
a.
b.
c.
d. Total of lines 8a, 8b and 8c
9. Total Corrected Tax Liability (Line 7 plus line 8d)
10. Total Tax you showed on your Return or as Previously Adjusted
11. Adjustments to Earned Income Credit/Fuels Credits - increase (decrease)
12. Increase in Tax or (Decrease in Tax)
(Line 9 adjusted by Lines 10 and 11)
13. Adjustments to Prepayment Credits - increase (decrease)
14. Amount you owe or (Overpayment) - (Line 12 adjusted by line 13)
Excluding interest and penalties
a.
15. Penalties
(See explanation)
b.
c.
Other Information (See notices on the back of this form.)
Examiner's Signature
District
Date
Consent to Assessment and Collection - I do not wish to exercise my appeal rights with the Internal Revenue Service or to contest in the United States Tax
Court the findings in this report. Therefore, I give my consent to the immediate assessment and collection of any increase in tax and penalties, and accept any
decrease in tax and penalties above, plus any interest as provided by law.
Signature of Taxpayer
Date
Signature of Taxpayer
Date
NOTE: If you filed a joint
return, both husband and
wife must sign this form.
Title
Date
By
4549-E
Cat. No. 13383E
Form
(Rev- 5-1993)