Form 8594 (Rev. December 2012) F8594
User Manual: 8594
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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)
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