.

46Enter .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 returnIdentifying 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 IComputation of Deduction

40Initial investment.....................40

41Subsequent investments (see instructions).............41

42Income reported on your tax returns for tax years prior to the discovery year  

(see instructions).....................42

43Add lines 40, 41, and 42..................43

44Withdrawals for all years (see instructions)  .............44

45Subtract line 44 from line 43. This is your total qualified investment......45

47Multiply line 46 by line 45..................47

48Actual recovery.....................48

49Potential insurance/Securities Investor Protection Corporation (SIPC) recovery     .    .49

50Add lines 48 and 49. This is your total recovery............50

51Subtract 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 IIRequired 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 

----------------Page (0) Break----------------