Form 8937 Report of Organizational Actions Basis of Securities

Version A, Cycle 1

12
Form

8937

Report of Organizational Actions
Affecting Basis of Securities

(Rev. XX-2011)

OMB No. 1545-XXXX

Department of the Treasury
Internal Revenue Service

Part I

Reporting Issuer

1 Issuer's name

2 Issuer's employer identification number (EIN)

3 Number and street (or P.O. box if mail is not delivered to street address)

4 Account number

5 City, town, or post office, state, and ZIP code

6 Date of action

Email
7 Name of contact for additional information 8 Telephone number of contact

(
10 CUSIP number

Part II

11 Serial number

9 email address of contact

)
12 Ticker symbol

13 Classification description

Organizational Action

DRAFT AS OF
March 1, 2011

For Paperwork Reduction Act Notice, see the separate Instructions.

Cat. No. 37752P

Form 8937 (Rev. XX-2011)

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Instructions for Form 8937

Department of the Treasury
Internal Revenue Service

(Rev. December 2011)

Section references are to the Internal Revenue Code unless
otherwise noted.

Where to File

General Instructions

File Form 8937 with the Department of the Treasury,
Internal Revenue Service Center, ???????

Who Must File

Exceptions

File Form 8937 if you are an issuer of a specified security
that takes an organizational action that affects the basis
of that security. A specified security is:
• Any share of stock in a corporation,
• Any note, bond, debenture, or other evidence of
indebtedness,
• Any commodity, or contract or derivative with respect
to such commodity, if adjusted basis reporting is
required, or
• Any other financial instrument that requires adjusted
basis reporting.

Issuer Statements
If you are required to file Form 8937 you must give a
copy of the return or a written issuer statement to each
security holder of record or to the security holder’s
nominee. If a written issuer statement is given, it must
indicate that the information is being reported to the IRS.
See Recipient statements, later.

Public Reporting
You are not required to file Form 8937 with the IRS, by
the due date, if you post the return with the required
information in a readily accessible format on your primary
public website or the primary public website of any
successor organization. You must keep the return
accessible for 10 years.

When to File
Form 8937 must be filed with the IRS on or before the
45th day following the organizational action, or, if earlier,
January 15 of the year following the calendar year of the
organizational action. Redemption occurs on the last day
a holder may redeem a security. You may file the return
before the organizational action if the quantitative effect
on basis is determinable.
To report the quantitative effect on basis by the
TIP due date, you may make reasonable assumptions
about the facts that cannot be determined before
the due date. A corrected return must be filed within 45
days of determining facts that result in a different
quantitative effect on basis from what was previously
reported. For additional information see Treasury
Regulations section 1.6045B-1(a)(2)(ii).
Penalty relief for 2011. You will not be penalized under
section 6721 if you do not file Form 8937 within 45 days
of an organizational action taken in 2011 provided that
you file the return (or make it publicly available on your
website) by January 17, 2012. For details, see Notice
2011-18, available at www.irs.gov/irb/2011-11_IRB/ar07/
html.

You are not required to furnish an issuer statement to the
holder of the security if:
• You reasonably determine that all holders and
nominees are exempt recipients under Treasury
Regulations section 1.6045-1(c)(3)(i)(B),
• You satisfy the public reporting requirements stated
earlier,
• You know the holder has completed an exemption
certificate,
• You know the recipient is a money market fund
described in Treasury Regulations section
1.6045-1(c)(3)(vi), or
• You know the recipient is an exempt recipient under
Treasury Regulations 1.6049-4(c)(1)(ii)(A) through (M).

Specific Instructions
Recipient Statements
You must give a separate statement to each security
holder of record as of the date of the organizational
action and all subsequent holders of record up to the
date you give the statement. If you record the security on
your books in the name of a nominee, you must give the
statement to the nominee in lieu of the holder. If the
nominee is the issuer, an agent of the issuer, or a plan
operated by the issuer, the issuer must give the
statement to the holder.
Time for furnishing statements. An issuer statement
must be given on or before January 15 of the year
following the calendar year of the organizational action. A
redemption occurs on the last day a holder may redeem
a security. A statement can be given before the
organizational action if the quantitative effect on basis
has been determined. However, a corrected return must
be given by the later of the due date or 45 days after
determining the facts, if a different quantitative effect on
basis is determined.

Part I
Reporting issuer. Report your name, taxpayer
identification number, and a contact name, address,
email address, and telephone number. Include the
identifiers of each security involved in the organizational
action including, the Committee on Uniform Security
Identification Procedures (CUSIP) number , classification
of the security (such as stock), account number, serial
number, and ticker symbol as well as any description
about the class of security affected.

Part II
Organizational action. Report the type or nature of the
organizational action, including the date of the action or

Cat. No. 57457H

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the date against which shareholders’ ownership is
measured for the action.
Quantitative effect. Report the quantitative effect of the
organizational action on the basis of the security in the
hands of a U.S. taxpayer as adjustment per share or as a
percentage of old basis. Include:
• A description of the calculation,
• The applicable Internal Revenue Code section and
subsection,
• The data supporting the calculation, such as market
values and valuation dates, and
• Any other information necessary to implement the
adjustment including the reportable year and if any loss is
recognized.

You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its
instructions must be retained as long as their contents
may become material in the administration of any Internal
Revenue law. Generally, tax returns and return
information are confidential, as required by section 6103.
The time needed to complete and file this form will
vary depending on individual circumstances. The
estimated average time is:

Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal Revenue
laws of the United States. You are required to give us the
information. We need it to ensure that you are complying
with these laws and to allow us to figure and collect the
right amount of tax.

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Learning about the law or the form . . . . . .

XX hr., XXmin.

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Copying, assembling, and sending the form
to the IRS . . . . . . . . . . . . . . . . . . . . . . . .

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