Form 13750 - Election To Participate In Announcement 2005-80 Settlement Initiative Page 3

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Details of Settlement Initiative Transactions Elected by Taxpayer
Schedule A
(A separate Schedule A must by submitted for each transaction checked in Section II of Form 13750)
Indicate the notice, ruling or other transaction description for the box checked in Section II to which this Schedule A applies
1. Please provide a detailed description of your particular transaction, including a description of the relevant tax benefits
(Including, but not limited to income deferrals, deductions, credits, exclusions, and basis adjustments)
(If additional space is required, please include information on a separate attachment to this schedule)
2. Enter the applicable Tax Shelter Registration (or Material Advisor) number (if registered)
3. Transaction details
Type of Tax
Tax Years
Amount of Tax
Amount of Tax Benefits
Line Item Where
Date Tax
(income, excise,
Involved
at Issue
Benefit Claimed
Return Filed
Claimed on Tax Return
employment, etc.)
(If additional space is required, please include information on a separate attachment to this schedule)
4. Transaction costs (i.e. fees and other amounts paid to promoters, attorneys, accountants, appraisers, or others to plan and carry
out the transaction)
Transaction Costs paid to
Tax Years
Amount(s)
Involved
Paid
Name
Business
Address
Relationship
(If additional space is required, please include information on a separate attachment to this schedule)
5. Other parties to the transaction (including but not limited to the names of employees who are affected by an employer's transactions)
Party Name
EIN/SSN
Address
Daytime Phone Number
(If additional space is required, please include information on a separate attachment to this schedule)
6. Are your tax matters with respect to this elected transaction currently in litigation
Yes
No
7. Has the Service informed you it has designated (or is considering designation
Yes
No
of) your transaction for litigation
Yes
No
8. Are you currently a party to any bankruptcy proceeding
Catalog No. 47521K
13750
Form
(10-2005)

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