Form 8594 Asset Acquisition Statement

2
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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8594, PAGE 1 of 2
MARGINS: TOP 1⁄2", CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 17" x 11"
FOLD TO: 8 1⁄2" x 11" PERFORATE: (ON FOLD)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

8594

Action

Date

O.K. to print
Revised proofs
requested

Asset Acquisition Statement

Form
(Rev. February 2006)

Signature

OMB No. 1545-1021

Under Section 1060

Department of the Treasury
Internal Revenue Service

䊳

Attach to your income tax return.

䊳

Attachment
Sequence No.

See separate instructions.

Name as shown on return

61

Identifying number as shown on return

Check the box that identifies you:
Purchaser
Seller

Part I

General Information

1 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 Date of sale

Part II
4

3 Total sales price (consideration)

Original Statement of Assets Transferred

Assets

Aggregate fair market value (actual amount for Class I)

Allocation of sales price

Class I

$

$

Class II

$

$

Class III

$

$

Class IV

$

$

Class V

$

$

Class VI and VII

$

$

Total

$

$

5

6

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?
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

Yes

No

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 schedule 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. 2-2006)

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8594, PAGE 2 of 2
MARGINS: TOP 1⁄2", CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 17" x 11" FOLD TO: 8 1⁄2" x 11"
PERFORATE: (ON FOLD)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

2
Supplemental Statement—Complete only if amending an original statement or previously filed
supplemental statement because of an increase or decrease in consideration. See instructions.

Form 8594 (Rev. 2-2006)

Part III

Page

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. 2-2006)