Sample Form 4549-A - Income Tax Examination Changes, Page 2The sample form is an example of Page 2 of Form 4549-A, which is the basic report form prepared by examiners for unagreed and excepted agreed individual and corporate income tax cases. The sample form is an example of a completed form reflecting the taxpayer name, TIN etc., including the following remarks in the Other Information: The dividends declared and paid with the claim filed on Form 976 have been allowed in full.