Form 8594 Asset Acquisition Statement

Asset Acquisition Statement

8594

OMB No. 1545-1021

Under Section 1060

Form
(Rev. December 2012)

Department of the Treasury
Internal Revenue Service

▶

Attachment
Sequence No.

▶ Attach to your income tax return.
Information about Form 8594 and its separate instructions is at www.irs.gov/form8594

Name as shown on return

169

Identifying number as shown on return

Check the box that identifies you:
Purchaser
Seller

Part I
1

General Information

Name of other party to the transaction

Other party’s identifying number

Address (number, street, and room or suite no.)

City or town, state, and ZIP code

2

3 Total sales price (consideration)

Date of sale

Original Statement of Assets Transferred

Part II
4

Aggregate fair market value (actual amount for Class I)

Assets

Allocation of sales price

Class I

$

$

Class II

$

$

Class III

$

$

Class IV

$

$

Class V

$

$

Class VI and VII

$

$

Total
$
$
5 Did the purchaser and seller provide for an allocation of the sales price in the sales contract or in another
written document signed by both parties? . . . . . . . . . . . . . . . . . . . . . .

Yes

No

If “Yes,” are the aggregate fair market values (FMV) listed for each of asset Classes I, II, III, IV, V, VI, and VII
the amounts agreed upon in your sales contract or in a separate written document? . . . . . . . .

Yes

No

6 In the purchase of the group of assets (or stock), did the purchaser also purchase a license or a covenant
not to compete, or enter into a lease agreement, employment contract, management contract, or similar
arrangement with the seller (or managers, directors, owners, or employees of the seller)? . . . . . .

Yes

No

If “Yes,” attach a statement that specifies (a) the type of agreement and (b) the maximum amount of
consideration (not including interest) paid or to be paid under the agreement. See instructions.
For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 63768Z

Form 8594 (Rev. 12-2012)

Form 8594 (Rev. 12-2012)

Page

2

Part III Supplemental Statement—Complete only if amending an original statement or previously filed supplemental
statement because of an increase or decrease in consideration. See instructions.
7 Tax year and tax return form number with which the original Form 8594 and any supplemental statements were filed.

8

Assets

Allocation of sales price as previously reported

Increase or (decrease)

Redetermined allocation of sales price

Class I

$

$

$

Class II

$

$

$

Class III

$

$

$

Class IV

$

$

$

Class V

$

$

$

Class VI and VII

$

$

$

Total
$
9 Reason(s) for increase or decrease. Attach additional sheets if more space is needed.

$

Form 8594 (Rev. 12-2012)