Part 2: Required statements and declarations (see instructions)

I am claiming a theft loss deduction pursuant to IRS 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 Section C, Part 1. I am a qualified investor as defined in IRS Revenue Procedure 2009-20, Section 4.03.

If I have determined the amount of my theft loss deduction using 0.95 on line 35 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 IRS Revenue Procedure 2009-20, Section 4.10.

I agree to comply with the conditions and agreements set forth in IRS Revenue Procedure 2009-20 and Section C.

If I have already filed a return or amended return that does not satisfy the conditions in IRS Revenue Procedure 2009-20, Section 6.02.

I agree to all adjustments or actions that are necessary to comply with those conditions. The tax years for which I filed the returns or amended returns and the dates on which they were filed are as follows:

____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _______________________________________________