Sample Form 4549-A - Income Tax Examination Changes, Page 1The sample form is an example of Page 1 of Form 4549-A, which is the basic report form prepared by examiners for unagreed and excepted agreed individual and corporate income tax cases. Page 1 contains fields for the taxpayer name, TIN, proposed adjustments, and the resulting tax or overassessment. The sample form is an example of a completed form reflecting the taxpayer name, no adjustments, the figures for AGI per return and as corrected display the same number, the figures for Taxable Income per return and as corrected display the same number. Line 10 (a) Plus Other Taxes displays See Attached Schedule with a number of $17,388, representing the personal holding company tax. Line 13 titled, Adjustments to: displays PHC Deficiency Dividends Deduction with a number of ($17,388). Line 14, Deficiency, and Line 16, Balance Due, show zero.