Form 4684 (2013)
Attachment Sequence No.  
26
Page 
2
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
Part I
Casualty or Theft Gain or Loss  
(Use a separate Part l for each casualty or theft.)
19
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 casualty or theft. If line 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 in 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
........
25
26
Enter the 
smaller
 of line 20 or line 25 
.....
26
Note: 
 
 
27
Subtract line 21 from line 26. If zero or less, enter -0-
27
28
or
28
Part II
Summary of Gains and Losses  
(from separate Parts l)
(b)  
Losses from casualties or thefts
(a)  
Identify casualty or theft
(i)  
Trade, business,
 
rental or royalty
 
property
(ii)  
Income-
 
 
producing and
 
employee property
(c)  
Gains from
 
casualties or thefts
 
includible in income
Casualty or Theft of Property Held One Year or Less
     
                                                                                             
29
(
)
(
)
(
)
(
)
30
Totals. Add the amounts on line 29
............
30
(
)
(
)
31 
Combine line 30, 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
.......................
31
32 
Enter the amount from line 30, 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, partnerships, and S corporations, see instructi
ons
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 (b)(i) and (b)(ii)
.....
35
(
)
(
)
36
Total gains. Add lines 33 and 34, column (c)
......................
36
37
Add amounts on line 35, columns (b)(i) and (b)(ii)
....................
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 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
.........
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 1120S, Schedule K, line 10.
Form 
4684
 (2013)
Description of properties (show type, location, and date acquired for each property). Use a separate line for each property lost or damaged  
If the property was totally destroyed by casualty or 
lost from theft, enter on line 26 the amount from line 20.
Casualty or theft loss. Add the amounts on line 27. Enter the total here and on line 29
      
line 34 (see instructions)
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