Schedule A (Form 8975) - Tax Jurisdiction And Constituent Entity Information

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SCHEDULE A
Tax Jurisdiction and Constituent Entity Information
(Form 8975)
For reporting period beginning
, 20
, and ending
, 20
OMB No. 1545-2272
(June 2017)
A separate Schedule A (Form 8975) is to be completed for each tax jurisdiction of the multinational enterprise group.
▶
Department of the Treasury
Information about Schedule A (Form 8975) and its separate instructions is at
Internal Revenue Service
▶
Name of the reporting entity
EIN
Part I
Tax Jurisdiction Information. All financial amounts must be stated in U.S. dollars. See instructions.
Tax jurisdiction
1. Revenues
2. Profit (loss) before
3. Income tax paid
4. Income tax
5. Stated capital
6. Accumulated
7. Number of
8. Tangible assets
income tax
(on cash basis)
accrued—current
earnings
employees
other than cash and
(a)
(b)
(c)
year
cash equivalents
Unrelated party
Related party
Total
Part II
Constituent Entity Information
1. Constituent entities resident in
2. TIN
3. Tax jurisdiction of
4. Main business activities
the tax jurisdiction
organization or
incorporation if
(a)
(b)
different from tax
jurisdiction of
Activity code
If you entered the code for “Other,” describe the
residence
business activity
For Paperwork Reduction Act Notice, see separate instructions.
Schedule A (Form 8975) (6-2017)
Cat. No. 69310N

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