Statement of Dissolved Entities

OMB Number
1545- xxxx

Statement on Dissolved Entities
In re:

,
Taxpayer name
Taxpayer Identification Number
I controlled and/or was beneficial owner of the following foreign entities (the “Offshore Entities”) during the periods indicated:
Entity 1
Entity name
Entity type
Jurisdiction
Date entity formed
Date entity dissolved/terminated

Entity 2
Entity name
Entity type
Jurisdiction
Date entity formed
Date entity dissolved/terminated

Entity 3
Entity name
Entity type
Jurisdiction
Date entity formed
Date entity dissolved/terminated

DRAFT AS OF
March 5, 2013

During the periods indicated above (date formed through dates dissolved/terminated), I used the above entities for the purpose of holding foreign
accounts and/or assets without disclosing my beneficial ownership. The Offshore Entities purported to be separate and apart from me but, in actuality,
acted as my nominee or alter ego in holding the financial accounts and/or assets. I treated the financial accounts and/or assets of the Offshore Entities
as my personal assets and accounts at all times after the formation of the Offshore Entities. The financial accounts and/or assets held in the names of
the entities were my assets.
I further acknowledge that during the period(s) stated above, I was responsible for filing information returns, including Forms 5471 for corporations and/
or Forms 3520 and 3520-A for trusts and similar entities. Because these entities had no business purpose other than to act as my nominees, I request
that the I.R.S. waive the requirement that I file such delinquent information returns as a condition of resolving my voluntary disclosure. In lieu of filing
these returns, I will dissolve or terminate these entities prior
to entering into a specific matters closing agreement resolving my voluntary disclosure and provide information about their dissolution or termination
upon request. I agree that if the I.R.S. waives this filing requirement, the waiver will have no effect on the applicability of I.R.C. § 6501(c)(8).
Under the penalties of perjury, I declare that I examined the above statements, and, to the best of my knowledge and belief, they are true, correct, and
complete.

Signatures
Name (print)

Taxpayer signature

Date signed

Name (print)

Taxpayer signature

Date signed

Privacy Act and Paperwork Reduction Notice
We ask for the information on this statement on dissolved entities to carry out the Internal Revenue laws of the United States. Our authority to ask for information is sections 6001, 6109, 7801,
7803 and the regulations thereunder. This information will be used to determine and collect the correct amount of tax under the terms of the offshore voluntary disclosure program. You are not
required to apply for participation in the offshore voluntary disclosure program. If you choose to apply, however, you are required to provide all the information requested on the statement on
dissolved entities.
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document displays a valid OMB control number. Books or
records relating to a document or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by section 6103. Section 6103, however, allows or requires the Internal Revenue Service to disclose or give this information to others as
described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to enforce the tax laws, both civil and criminal, and to cities, states, the
District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state
agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent
processing your application. Providing false information may subject you to penalties.
The time needed to complete and submit the statement on dissolved entities will vary depending on individual circumstances. The estimated average time is: 1 hour.

Form

14467 (3-2013)

Catalog Number 61793Q

www.irs.gov

Department of the Treasury - Internal Revenue Service