Form 8806 - Information Return For Acquisition Of Control Or Substantial Change In Capital Structure

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8806

Information Return for Acquisition of Control

Form

or Substantial Change in Capital Structure

OMB No. 1545-0123

(Rev. October 2016)

Department of the Treasury

Information about Form 8806 and its instructions is at

▶

Internal Revenue Service

Part I

Reporting Corporation (see instructions)

Name of reporting corporation

Address of reporting corporation

EIN of reporting corporation

Name of reporting corporation’s common parent, if any

Address of reporting corporation’s common parent

EIN of reporting corporation’s common parent

Part II

Acquiring Corporation (see instructions)

Name of acquiring corporation

Address of acquiring corporation

EIN of acquiring corporation

Was the acquiring corporation newly formed prior to its involvement in the transaction?

Yes

Name of acquiring corporation’s common parent, if any

Address of acquiring corporation’s common parent

EIN of acquiring corporation’s common parent

Part III

Information About Acquisition of Control or Substantial Change in Capital Structure

Date of transaction(s) that resulted in the acquisition of control or substantial change in capital structure

Description of the transaction(s)

▶

Did the reporting corporation’s shareholders receive any stock or other property in exchange for their stock in the

reporting corporation, for which the reporting corporation has reasonably determined that the shareholders are required to

recognize gain (if any) from the exchange of such stock? If “Yes,” go to lines 6b and 6c

Yes

Fair market value of the stock or other property received

Description of the stock or other property received

▶

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and

Sign

belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Here

Date

Signature of officer

Print/Type preparer’s name

Preparer’s signature

Date

PTIN

Paid

Check

self-employed

Preparer

Use Only

Firm’s name

Firm’s EIN

▶

Firm's address

Phone no.

▶

Part IV

Consent Election

Does the reporting corporation consent to the publication of its name and address, date of transaction(s), description of

shares affected by the transaction(s) and the amount of cash and fair market value of any property provided to each class

of shareholders in exchange for a share, on an IRS website and/or in an IRS publication, as described in Regulations

section 1.6043-4(a)(2), to assist brokers to satisfy their reporting obligations under Regulations section 1.6043-4(b)? .

Yes

Under penalties of perjury, I declare that I am an officer of the above named corporation and that I am authorized to give consent on behalf of the above named corporation

for the IRS to publish the information necessary to enable brokers to satisfy their reporting obligations under Regulations section 1.6043-4(b).

Sign

Here

Signature of officer

Date

Title

8806

For Paperwork Reduction Act Notice, see the instructions.

Form

(Rev. 10-2016)

Cat. No. 10085T