.
46
Enter .95 (95%) if you have no potential third-party recovery. Enter .75 (75%) if you 
have potential third-party recovery
...............
46
Form 4684 (2013)
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.)
Part I
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
......
45
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
............
50
51
Subtract line 50 from line 47. This is your deductible theft loss. Include this amount on 
line 28. Do not complete lines 19-27 for this loss. Then complete Section B, Part II    .
51
Part II
Required Statements and Declarations
 (See instructions.)
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.
any potential third-party recovery, as that term is defined in section 4.10 of Revenue Procedure 2009-20.
date(s) on which they were filed are as follows:
Form 
4684
 (2013)
• I agree to comply with the conditions and agreements set forth in Revenue Procedure 2009-20 and this Section C.
• I am claiming a theft loss deduction pursuant to Revenue Procedure 2009-20 from a specified fraudulent arrangement conducted by the following 
• If I have determined the amount of my theft loss deduction using .95 on line 46 above, I declare that I have not pursued and do not intend to pursue 
• 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 return(s) or amended return(s) and the 
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