EFTA01222706.pdf

Casualties and Thefts Fom4684 ► Go to wwwirs.gov/Form4684 for Instructions and the latest information. OMB No. 1545-017? 2017 Department of the Treasury ► Attach to your tax return. Attachment Internal Revenue Service ► Use a separate Form 4684 for each casualty or theft. Sequence No. 26 Name(s) shown on tax return Identifying number SECTION A—Personal Use Property (Use this section to report casualties arid thefts of property not used in a trade or business or for income-producing purposes. If reporting a casualty loss from a disaster, see the instructions before completing this section.) 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. You must use a separate Form 4684 (through line 12) for each casualty or theft event involving personal use property. Property A Property B Property C Property D Properties A B C D 2 Cost or other basis of each property 2 3 Insurance or other reimbursement (whether or not you filed a claim) (see instructions) 3 Note: If tine 2 is more than line 3. skip line 4. 4 Gain from casualty or theft. If line 3 is more than line 2, enter the difference here and skip lines 5 through 9 for that column. See instructions if tine 3 includes insurance or other reimbursement you did not claim, or you received payment for your loss in a later tax year . 4 5 Fair market value before casualty or theft 6 6 Fair market value after casualty or theft e 7 Subtract line 6 from line 5 7 8 Enter the smaller of line 2 or line 7 8 9 Subtract line 3 from line 8. If zero or less. enter -0- . . 9 10 Casualty or theft loss. Add the amounts on line 9 in columns A through D 10 11 Enter $100 ($500 if qualified disaster loss rules apply: see instructions) 11 12 Subtract line 11 from line 10. If zero or less: enter -0- 12 Caution: Use only one Form 4684 for lines 13 through 18. 13 Add the amounts on line 12 of all Forms 4684 13 14 Add the amounts on line 4 of all Forms 4684 14 Caution: See instructions before completing line 15. 15 • If tine 14 is more than line 13. enter the difference here and on Schedule D. Do not complete the rest of this section. • If tine 14 is equal to tine 13, enter -0- here. Do not complete the rest of this section. • If line 14 is less than line 13. and you have no qualified disaster losses subject to the $500 reduction on tine 11 on any Form(s) 4684, enter -0- here and go to line 16. If you have qualified disaster losses subject to the $500 reduction, subtract line 14 from line 12 15 of the Form(s) 4684 reporting those losses. If the result is zero or less, see instructions. Otherwise, enter that result here and on Schedule A (Form 1040). line 28. or Form 1040NR. Schedule A, line 14. If you claim the standard deduction, also include on Schedule A (Form 1040), line 28, the amount of your standard deduction (see the instructions for Form 1040). Do not complete the rest of this section if all of your casualty or theft losses are subject to the $500 reduction. 16 Add lines 14 and 15. Subtract the result from line 13 16 17 Enter 10% of your adjusted gross income from Form 1040, line 38. or Form 1040NR. line 37. Estates and trusts. see instructions 17 18 Subtract line 17 from line 16. If zero or less, enter -0-. Also enter the result on Schedule A (Form 1040). line 20. or Form 1040NR, Schedule A. line 6. Estates and trusts, enter the result on the "Other deductions" tine of your tax return 18 For Paperwork Reduction Act Notice. see instructions. Form 4684 (2017) EFTA01222706 Form 4684 (2017) Attachment Sequence No. 28 Page 2 Name(s) shown on tax return. Do not enter name and identifyng number if shown on other side. Identifying number SECTION 8-Business and Income-Producing Property Casualty or Theft Gain or Loss (Use a separate Part I for each casualty or theft.) 19 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. See instructions if claiming a loss due to a Ponzi-type Investment scheme and Section C is not completed. Property A Property B Property C Property D Properties A B C D 20 Cost or adjusted basis of each property 20 21 Insurance or other reimbursement (whether or not you filed a claim). See the instructions for line 3 . . . . 21 Note: If line 20 is more than line 21. skip line 22. 22 Gain from rntisalty or theft. If Ire 21 is more than line 20. enter the difference here and on line 29 or line 34. column (c). except as provided in the instructions for line 33. Also. skip lines 23 through 27 for that column. See the instructions for line 4 if line 21 includes insurance or other reimbursement you did not claim, or you received payment for your loss n a later tax year 22 23 Fair market value before casualty or theft 23 24 Fair market value after casualty or theft 24 25 Subtract line 24 from line 23 26 26 Enter the smaller of line 20 or line 25 26 Note: If the property was totally destroyed by casualty or lost from theft, enter on line 26 the amount from line 20. 27 Subtract line 21 from line 26. If zero or less, enter . re 28 Casualty or theft loss. Add the amounts on line 27. Enter the to I here and on line 29 or line 34 (see Instructions) . 128 Summamf Gains and Losses (from separate Parts I) 0) Losses from casualties or thefts (c) Gains from 0 Trade, business. •9 Income- casualties or thefts (a) Identify casualty or theft rental, or royally producing and includible it income Property employee property Casualty or Theft of Property Held One Year or Less 29 30 Totals. Add the amounts on line 29 I so 31 Combine line 30. columns (b)(1) and (c). Enter the net gain or (loss) here and on Form 4797, line 14. If Form 4797 is not otherwise required, see Instructions 31 32 Enter the amount from line 30, column (b)(i) here. Individuals. enter the amount from income-producing property on Schedule A (Form 1040). line 28, or Form 1040NR. Schedule A. line 14, and enter the amount from property used as an employee on Schedule A (Form 1040). ire 23. or Form 1040NFt, Schedule A, line 9. Estates and trusts. partnerships, and S corporations, see instructions 32 Casualty or Theft of Property Held More Than One Year 33 Casualty or theft gains from Form 4797, line 32 33 34 ) ) ) 35 Total losses. Add amounts on line 34, columns (Mend MOO 36 ) ) 36 Total gains. Add lines 33 and 34, column (c) 36 37 Add amounts on line 35, columns (b)(0 and (b)00 37 38 If the loss on line 37 Is more than the gain on line 36: a Combine line 35. column (b)(I) and line 36. 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 . . . . . . . . . . . . . . . . . . . . . 38a b Enter the amount from line 35. 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 14. and enter the amount from property used as an employee on Schedule A (Form 1040), line 23, or Form 1040NR, Schedule A. line 9. Estates and trusts, enter on the "Other deductions" line of your tax velum. Partnerships (except electing large partnerships) and S corporations. see the note below. Electing large partnerships, enter on Form 1065-B. Part II. line 11 38b 39 If the loss on line 37 is less than or equal to the gain on line 36, combine lines 36 and 37 and enter here. Partnerships (except electing large partnerships), see the note below. All others, enter this amount on Form 4797. line 3 . . . . 39 Note: Partnerships, enter the amount from line 38a, 38b. or line 39 on Form 1065. Schedule K, line 11. S corporations, enter the amount from line 38a or 38b on Form 11205, Schedule K, tine 10. Form 4684 (2017) EFTA01222707 Forrn 4684 (2017) Attachment Sequence No. 26 Page 3 Name(s) shown on tax return Identifying number SECTION C—Theft Loss Deduction for Ponzi-Type Investment Scheme Using the Procedures in Revenue Procedure 2009-20 (Complete this section in lieu of Appendix A in Revenue Procedure 2009 20. See instructions.) aigau Computation of Deduction 40 Initial investment 40 41 Subsequent Investments (see Instructions) 41 42 Income reported on your tax returns for tax years prior to the discovery year (see Instructions) 42 43 Add lines 40, 41. and 42 43 44 Withdrawals for all years (see instructions) 44 45 Subtract line 44 from line 43. This is your total qualified investment 46 46 Enter 0.95 (95%) if you have no potential third-party recovery. Enter 0.75 (75%) if you have potential third-party recovery 48 47 Multiply line 46 by line 45 47 48 Actual recovery 48 49 Potential insurance/Securities Investor Protection Corporation (SIPC) recovery . 49 50 Add lines 48 and 49. This is your total recovery 60 51 Subtract line 50 from line 47. This is your deductible theft toss. Include this amount on line 28 of Section B, Part I. Do not complete lines 19-27 for this loss. Then complete Section 8, Part II 61 iii21111 Required Statements and Declarations (See instructions.) • I am claiming a theft loss deduction pursuant to Revenue Procedure 2009.20 from a specified fraudulent arrangement conducted by the following Individual or entity. Name of individual or entity Taxpayer identification number (if known) Address • I have written documentation to support the amounts reported in Part I of this Section C. • I am a qualified investor as defined in section 4.03 of Revenue Procedure 2009.20. • If I have determined the amount of my theft loss deduction using 0.95 on line 46 above. I declare that I have not pursued and do not intend to pursue any potential third-party recovery, as that term is defined in section 4.10 of Revenue Procedure 2009.20. • I agree to comply with the conditions and agreements set forth in Revenue Procedure 2009.20 and this Section C. • If I have already filed a return or amended return that does not satisfy the conditions in section 6.02 of Revenue Procedure 2009.20. I agree to all adjustments or actions that are necessary to comply with those conditions. The tax year(s) for which I filed the retum(s) or amended retum(s) and the date(s) on which they were filed are a follows: Form 4684 (2017) EFTA01222708 Ferri 4684 (2017) Attachment Sequence No. 26 Page 4 Name(s) shown on tax return Identifying number SECTION D—Election To Deduct Federally Declared Disaster Loss in Preceding Tax Year (See instructions.) LEM Election Statement By providing all of the information below and attaching this Section D to a velum or amended return for the preceding tax year which takes advantage of the disaster loss deduction, you hereby elect, under section 165{0 of the Internal Revenue Code, to deduct a loss attributable to a federally declared disaster that occurred in a federally declared disaster area and was sustained in the disaster year on your tax return for the preceding tax year. 52 Provide the name or a description of the federally declared disaster. 53 Provide the date or dates (mm/dcVyyyy) of the loss or losses that arose from the federally declared disaster. 54 Specify the address. Including the city or town, county or parish, state and ZIP code where the damaged or destroyed property was located at the time of the disaster. IMES Revocation of Prior Election By providing all of the Information below and attaching this Section D to an amended return for the preceding tax year which eliminates the previous disaster loss deduction, you hereby revoke a poor election under section 165(i) of the Internal Revenue Code to deduct a loss attributable to a federally declared disaster that occurred in a federally declared disaster area and was sustained in the disaster year on your tax return for the preceding tax year. 55 Provide the name or a description of the federally declared disaster and the address of the property that was damaged or destroyed and for which the election was claimed. 56 Specify the date (mm/dcl/yyyy) you fried the prior election, which you are now revoking. (See instructions and note that new rules went into effect on October 13. 20163 57 Enclose your payment or otherwise provide evidence for, or explanation of, your arrangements for the repayment of the amount of any credit or refund which you received and which resulted from the prior election (which you are now revoking). Form 4684 (2017) EFTA01222709