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Federal housing law

1225 Form 8876 (PDF)

Federal housing law as enacted — verbatim and citable.

Edition
2026-10-03
Last updated
2026-10-04
Jurisdiction
United States
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Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8876.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Form

8876

Excise Tax on Structured Settlement Factoring Transactions

OMB No. 1545-1826

Department of the Treasury Go to www.irs.gov/Form8876 for instructions and the latest information. Internal Revenue Service

Date of receipt of structured settlement payment rights . . . . . . . . . . . . . . . . .

Name Identifying number

Number, street, and room or suite no. (If a P.O. box, see instructions.)

City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **2 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **3 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **4 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **5 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **6 **
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
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.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
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**5 **
Less: Tax paid with Form 7004, if any
.
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.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
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.
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.
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.
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.
.
.
.
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.
**5 **
Less: Tax paid with Form 7004, if any
.
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.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
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.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
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.
.
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.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 7a
City or town State or province Country ZIP or foreign postal code
**1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **
Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number		 **1 **
Total undiscounted amount of structured settlement payments being acquired .
.
.
.
.
.
**2 **
Total amount paid for the above structured settlement payment rights .
.
.
.
.
.
.
.
.
**3 **
Factoring discount. Subtract line 2 from line 1 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**4 **
**Tax.**Multiply line 3 by 40% (0.40) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**5 **
Less: Tax paid with Form 7004, if any
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**6 **

Tax due. If line 4 is equal to or greater than line 5, subtract line 5 from line 4. For details on how
to pay, go to_www.irs.gov/Payments_ or see instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
**7 **

a Overpayment. If the amount on line 5 is more than the amount on line 4, subtract line 4 from line
5 and complete lines 7b, 7c, and 7d .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
**b ** Routing number
cType:
Checking
Savings
d Account number
City or town State or province Country ZIP or foreign postal code
Sign
Here		 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)



 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature
Date
Title (if any)
Paid
Preparer
Use Only		 Preparer’s name Preparer’s signature Preparer’s signature Preparer’s signature Date Check if
self-employed		 Check if
self-employed		 Check if
self-employed		 PTIN PTIN
Paid
Preparer
Use Only		 Firm’s name Firm’s name Firm’s name Firm’s name Firm’s name Firm’s EIN Firm’s EIN Firm’s EIN Firm’s EIN Firm’s EIN
Paid
Preparer
Use Only		 Firm’s address Firm’s address Firm’s address Firm’s address Firm’s address Phone no. Phone no. Phone no. Phone no. Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 33529K Form 8876 (Rev. 12-2025) Created 6/17/25

Exceptions & meaning →

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