Form 8947 - Report Of Branded Prescription Drug Information
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9Form 8947: Report of Branded Prescription Drug Information
Information about Form 8947 and its instructions is at
▶
Read the instructions before you complete Form 8947.
OMB No. 1545-2192
(Rev. October 2012)
Department of the Treasury — Internal Revenue Service
Item A: Check one
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First time Filer (Complete this page and page 6; attach Schedule A)
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Information report for
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Subsequent Year Filer with Changes (Complete this page and page 6; attach Schedules B, C, and D as needed) .
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sales year:
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Subsequent Year Filer with No Changes and Reporting Rebates (Complete this page and page 6; attach Schedule D)
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Subsequent Year Filer with No Changes and Not Reporting Rebates (Complete this page and page 6)
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2011
Entity name
Item B: Check one (see instructions)
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Single-person covered entity
Address (number and street). If you have a P.O. box, see instructions.
Designated entities:
2a
Common parent of an
affiliated group .
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City, town or post office, state, and ZIP code. If you have a foreign address, see instructions.
2b
Other designated entity
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Employer identification number (EIN).
Part I
Controlled Group Members
If you checked Item B, box 2a or 2b: Beginning with the name of the designated entity, list the information for all
members of the controlled group who, as of the end of the day on December 31, 2011, are manufacturers or importers
with gross receipts from the sale of branded prescription drugs to specified government programs (or sales due to
coverage under the programs).
Check if the entity
(c)
(a)
(b)
was not listed on
Employer
Name of entity
Address of entity
your report for
identification no.
sales year 2010
8947
For Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 10-2012)
Cat. No. 37765S
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