Form 4684 Form 4684 Casualties and Thefts

Form

Version A, Cycle 2

4684

Casualties and Thefts

OMB No. 1545-0177

2009

See separate instructions.
to your tax return.
© Use a separate Form 4684 for each casualty or theft.
©

© Attach

Department of theTreasury
Internal Revenue Service
Name(s) shown on tax return

Attachment
Sequence No. 26
Identifying number

SECTION A—Personal Use Property (Use this section to report casualties and thefts of property not used in a trade
or business or for income-producing purposes.)
1 Description of properties (show type, location, and date acquired for each property). Use a separate line for each property lost or damaged from
the same casualty or theft.
Property A
Property B
Property C
Property D

DRAFT AS OF
June 16, 2009
Properties

A

2 Cost or other basis of each property .

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3 Insurance or other reimbursement (whether or not you
filed a claim) (see instructions) . . . . . . . .
Note: If line 2 is more than line 3, skip line 4.
4 Gain from casualty or theft. If line 3 is more than line 2,

B

C

D

2
3

enter the difference here and skip lines 5 through 9 for that
column. See instructions if line 3 includes insurance or other
reimbursement you did not claim, or you received payment
for your loss in a later tax year . . . . . . . .

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5 Fair market value before casualty or theft . . . .
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6 Fair market value after casualty or theft . . . . .
7 Subtract line 6 from line 5 . . . . . . . . .
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8 Enter the smaller of line 2 or line 7 . . . . . .
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9 Subtract line 3 from line 8. If zero or less, enter -0- . .
10 Casualty or theft loss. Add the amounts on line 9 in columns A through D .
11 Enter the smaller of line 10 or $500 . . . . . . . . . . . .
12 Subtract line 11 from line 10 . . . . . . . . . . . . . .
Caution: Use only one Form 4684 for lines 13 through 24.
13 Add the amounts on line 12 of all Forms 4684 . . . . . . . . .

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14 Add the amounts on line 4 of all Forms 4684. . . . . . . . . . . . . .
15 ● If line 14 is more than line 13, enter the difference here and on Schedule D. Do not
complete the rest of this section (see instructions).
● If line 14 is less than line 13, enter -0- here and go to line 16.
● If line 14 is equal to line 13, enter -0- here. Do not complete the rest of this section.

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16 If line 14 is less than line 13, enter the difference . . . . . . . . . . . . . .
17 Add the amounts on line 12 of all Forms 4684 on which you entered a disaster loss (see instructions)

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18 Is line 17 more than line 14?
Yes. Enter the difference. If you are filing Schedule A (Form 1040), go to line 19. Otherwise, enter this amount
on line 6 of Schedule L (Form 1040A or 1040). Do not complete the rest of Section A. Form 1040NR filers, see
instructions.
No. Enter -0-. If you claim the standard deduction, do not complete the rest of Section A. . . . . . .
19 Subtract line 18 from line 16 . . . . . . . . . . . . . . . . . . . . . . . . . .
20 Enter 10% of your adjusted gross income from Form 1040, line 38, or Form 1040NR, line 36. Estates and trusts, see instructions
21 Subtract line 20 from line 19. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . .
22 Add lines 18 and 21. Also enter the result on Schedule A (Form 1040), line 20, or Form 1040NR, Schedule A, line 8.
Estates and trusts, enter the result on the "Other deductions" line of your tax return . . . . . . . . . .
For Paperwork Reduction Act Notice, see page 5 of the instructions.
Cat. No. 12997O

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Form 4684 (2009)

Version A, Cycle 2
Page 2

Attachment Sequence No. 26

Form 4684 (2009)

Name(s) shown on tax return. Do not enter name and identifying number if shown on other side.

Identifying number

SECTION B—Business and Income-Producing Property
Casualty or Theft Gain or Loss (Use a separate Part l for each casualty or theft.)
Part I
23 Description of properties (show type, location, and date acquired for each property). Use a separate line for each property lost or damaged
from the same casualty or theft.
Property A
Property B
Property C
Property D

DRAFT AS OF
June 16, 2009
Properties

B

A

24 Cost or adjusted basis of each property . . . . .
25 Insurance or other reimbursement (whether or not you

24

filed a claim). See the instructions for line 3 . . .
Note: If line 24 is more than line 25, skip line 26.

25

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C

D

26 Gain from casualty or theft. If line 25 is more than line 24, enter

the difference here and on line 33 or line 38, column (c), except as
provided in the instructions for line 37. Also, skip lines 27 through
31 for that column. See the instructions for line 4 if line 25 includes
insurance or other reimbursement you did not claim, or you
received payment for your loss in a later tax year. . . . .

27 Fair market value before casualty or theft .

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28 Fair market value after casualty or theft .
29 Subtract line 28 from line 27 . . . .
30 Enter the smaller of line 24 or line 29 .

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28
29
30

Note: If the property was totally destroyed by casualty or lost
from theft, enter on line 30 the amount from line 24.
31 Subtract line 25 from line 30. If zero or less, enter -031
32 Casualty or theft loss. Add the amounts on line 31. Enter the total here and on line 33 or line 38 (see instructions) .

Part II

Summary of Gains and Losses (from separate Parts l)

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(b) Losses from casualties or thefts

(a) Identify casualty or theft

(c) Gains from
casualties or thefts
includible in income

(ii) Incomeproducing and
employee property

(i) Trade, business,
rental or royalty
property

Casualty or Theft of Property Held One Year or Less
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34 Totals. Add the amounts on line 33 . . . . . . . . . . . .
35 Combine line 34, columns (b)(i) and (c). Enter the net gain or (loss) here and on Form 4797, line 14. If Form 4797 is
not otherwise required, see instructions . . . . . . . . . . . . . . . . . . . . . . .

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36 Enter the amount from line 34, column (b)(ii) here. Individuals, enter the amount from income-producing property on Schedule A (Form
1040), line 28, or Form 1040NR, Schedule A, line 16, and enter the amount from property used as an employee on Schedule A (Form
1040), line 23, or Form 1040NR, Schedule A, line 11. Estates and trusts, partnerships, and S corporations, see instructions . . . .

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Casualty or Theft of Property Held More Than One Year
37 Casualty or theft gains from Form 4797, line 32 . . . . . . . . . . . . . . . . . . . . . . . . .
(
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39 Total losses. Add amounts on line 38, columns (b)(i) and (b)(ii) . . . . .
40 Total gains. Add lines 37 and 38, column (c) . . . . . . . . . . . . . . . . . . . . . .
41 Add amounts on line 39, columns (b)(i) and (b)(ii) . . . . . . . . . . . . . . . . . . . .
42 If the loss on line 41 is more than the gain on line 40:
a Combine line 39, column (b)(i) and line 40, and enter the net gain or (loss) here. Partnerships (except electing large
partnerships) and S corporations, see the note below. All others, enter this amount on Form 4797, line 14. If Form
4797 is not otherwise required, see instructions . . . . . . . . . . . . . . . . . . . . .
b Enter the amount from line 39, column (b)(ii) here. Individuals, enter the amount from income-producing property on
Schedule A (Form 1040), line 28, or Form 1040NR, Schedule A, line 16, and enter the amount from property used as
an employee on Schedule A (Form 1040), line 23, or Form 1040NR, Schedule A, line 11. Estates and trusts, enter on
the “Other deductions” line of your tax return. Partnerships (except electing large partnerships) and
S corporations, see the note below. Electing large partnerships, enter on Form 1065-B, Part II, line 11 . . . . .

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42b

43 If the loss on line 41 is less than or equal to the gain on line 40, combine lines 40 and 41 and enter here. Partnerships

(except electing large partnerships), see the note below. All others, enter this amount on Form 4797, line 3

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Note: Partnerships, enter the amount from line 42a, 42b, or line 43 on Form 1065, Schedule K, line 11.
S corporations, enter the amount from line 42a or 42b on Form 1120S, Schedule K, line 10.
Form 4684 (2009)