6
Form 8947 (Rev. 10-2011)
Page
Summary of Form 8947
Schedule E
Entity name
Employer identification number (EIN).
1
Total number of controlled group members, including the designated entity, from page 1, Part I
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2
Total National Drug Codes (NDCs) from Schedule(s) A, column (b) .
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3
Total Medicaid state supplemental rebate amounts from Schedule(s) A, column (c)
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4
Total NDC additions from Schedule(s) B, Section I, column (b)
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5
Total Medicaid state supplemental rebate amounts from Schedule(s) B, Section I, column (c) .
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6
Total NDC deletions from Schedule(s) B, Section II .
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7
Total NDCs from Schedule(s) C, column (b)
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8
Total NDCs from Schedule(s) D, column (a) .
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9
Total Medicaid State supplemental rebate amounts from Schedule(s) D, column (b)
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Signature of Official Signing On Behalf of the Covered Entity (Single-Member, Common Parent of an
Part II
Affiliated Group, or Other Designated Entity) and Consent by the Common Parent or Designated Entity
(if applicable)
Under penalties of perjury, I declare that I have examined this report, including accompanying statements, and, to the best of my
knowledge and belief, it is true, correct, and complete.
[If you checked Item B, box 2a or 2b, on page 1] I also declare that I identified myself as the common parent of an affiliated group or
other designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to
the fee imposed by section 9008 of the Act and is to pay this fee to the IRS on behalf of the controlled group. Each entity that is a
member of the controlled group is jointly and severally liable for this fee. I further declare that each entity in the controlled group
identified on this report consents to the choice of the designated entity indicated on this report.
Sign
Here
Signature of official
Date
Title
Print name of signing official
Daytime telephone number
Email address
Send the forms in a flat mailing (not folded). Do not staple, tear, or tape any of these forms. If
Send Form 8947 to: Internal Revenue Service
you are sending a large number of forms in conveniently sized packages, write your name on
1973 Rulon White Boulevard
each package and number the packages consecutively. United States postal regulations
Mail Stop 4916
require forms and packages to be sent by First-Class Mail. However, you may use private
delivery services such as DHL, Federal Express (FedEx), and United Parcel Service (UPS).
Ogden, UT 84404
8947
Form
(Rev. 10-2011)