Form 10001 Request for Closing Agreement Relating to Advance Refund

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form 10001
(July 1996)

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t of the Treasury Intamal Revenue Service

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, OMB No.

Request lo; Closlng Agreement Relatlng I D Advancs ReiundJnp
lssur Under Ssctlons 148 and 7121 and Rev. Ptoc. 8 ~ 4 1 -

-15451491

I.Issuds M M

12. ~ S U W S
employer tdentification numba

5. W c i p a l amount of hue

.6. S& date of issue [rnrnmyy)

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7 . Enter bgulations under IRC 148 that appty to the isws

Oprn Mmrkmt Wudtlmr Inlormatlon

8. Namfslof sellerlsl of open market securtties pu-

0. Amount actually paid by the b u e r lor ths

ma

70. Tha spot price of the open markst 5ecuritim on the gak date of the open market wrjties
11. Amwm of brokerage commission p d to the Wla of !he

opsn rnarka a u n t i t s , if any

12.The value of a call omon H r w-on
Iw United States sacuritia -State and Local
Government %rim was cancell& in mnsctlon mttr the purchase ot the open marker smurities
13. P

m closing agree-

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amount

14. Attach copies of the fdIOWuig dOCUmwk

u ~ ~ o r ~ u ~ . ~ ~ t . n s u ~ h . l * . r r m w ~ ~ ~ ~ - y m ~ b o r u m r * a . ~ t M b r

~ ~ n d # M , t h l t r r r p r w w r ~ # I n w p p ~ n w t h l ~ * r ~ ~ ~ n g r p ~ m t m ~ t o ~ M a e o m p r r l

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Your signature

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Telephone number

Print name
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For ~ W u c U o n A e t H o ~ ~ b r e r t O f W ~

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Date I-,

lnstnrctlons for Form 10001
paper Amdudlon Acf W d p .
we ask lor this information to carry out the Internal Revenue laws of the United Slates. We n W It to ensure
tml lawpayers are complying wtth these laws and to a#ow us to figure and cotlect me dghl amount of ta*. You
are requited to plve us this irllomatlon L
I you wish to rtqusst to M t W fnt0 a doslnp spr99m~ntIn aWwdance
t.
wntn Me provisions of Revenue Procedure
you are not required to provide h e lntorma?lonrequested on s t a m that is subjst lo the Papemoh Reduction
AGf ~ n l the
w form d i i a y s a valld O M 8 mntml number. W a or m t d s relating to a form or Its Insfmetions
must be rstained as long as thek contents may beo~rnlematerlal in the edminlshtion of any t ntemat Revmus
h w . Generally, tar mtums and return Inlormation are confidential. as reqoired by Code decticln 6103.
The time need4 to complete this farm will v a v depending on Individual clrcumstancss. Ths estimated average
Ume is 3 b6.
H you havs comments concerning the accuracy of this time estimate or SUggBShlonS for making thls lorn simpler,
X'C ,mAd Se hsppy to hear tram yoc. Y3tl C B Wrfc.t
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!C !he T a Forms Cornmime, Westm Araa DlstritHrti~r!
Center, Rancho Gordcva. CA 95743-0001. Do Not send the form to tfils address. Instead, s m the W h e r e to
File" Lnstnretlons M o w .

Etfbctlve Data: R e q u ~ S t Sfor dosing agreements must bt, submh?tted usiw this lorn wfthln one year from

Requests for closiny agreements must b sent to the loRowing address:

Internal Revenue Service
Attention: -4F!Ee
P.O. Box 120

T 1 G E : ' r E R :0

gen Franklin Station
Washington, D.C. 20044
Who Must Sign:
A request for a doslng agreement must be signed by the issuer. The person d o sig~lsfor an lssuer must be
officlal ot the issuer who has personal knowtedge of the lacts and mom duties are not limited to obtaining a
dosing agrmment from the Service.

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Computln~of Cloalng Agreement Amount:
SM section 6 af Revenue Prwedure -1
for the omp put at ion of ths closing agrwrnent amount
8 p t hi-:

use of me q m ~p

r i of the nonpurpse investments Is not permitted H the period b e e n the sals bate and the
issue dale of the tan& was graeter than one month. The issuer must submit an ahernative catcularron
eaabllshing the fair markel value for Treasury seeuriti~sin such I n S t a ~ s .
se#on 6 of Revenue Pwmure
W Ifw aadditlmd inlcrmation

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