The image is Appendix A: Certification Statement Claiming Adjusted ASC 730 Financial Statement R&D as QREs. The statement includes: taxpayer name, taxpayer EIN, taxable year ending, relevant period(s) of applicable certified audited financial statement(s). There is a statement that reads: by signing this certification statements, taxpayer agrees to promptly provide (upon request of the IRS) all relevant data and records to establish to the satisfaction of the IRS that the statements made in this certification statement are true, correct and complete. I certify, under penalties of perjury, that for the taxable year ending (enter taxable year) the computation of Adjusted ASC 730 Financial Statement R&D has been computed in accordance with the definitions and methodology set forth in this guidance and that all information provided in accordance with this guidance, to the best of my knowledge and belief, is true, correct and complete. There are lines for signature, title and date. For corporations, the certification must be signed by an individual authorized under IRC 6062. This completed and signed certification statement must be provided to the LB&I examiner upon request within a time period subject to the LB&I IDR process.