Free Form 8594 (Rev. February 2006) - Federal

Form (Rev. February 2006)

8594

Asset Acquisition Statement
Under Section 1060
Attach to your income tax return. See separate instructions.

OMB No. 1545-1021 Attachment Sequence No.

Department of the Treasury Internal Revenue Service

61

Name as shown on return

Identifying number as shown on return

Check the box that identifies you: Purchaser Seller

Part I

General Information
Other party's identifying number

1 Name of other party to the transaction

Address (number, street, and room or suite no.)

City or town, state, and ZIP code

2 Date of sale

3 Total sales price (consideration)

Part II
4
Assets

Original Statement of Assets Transferred
Aggregate fair market value (actual amount for Class I) Allocation of sales price

Class I Class II Class III Class IV Class V Class VI and VII Total 5

$ $ $ $ $ $ $

$ $ $ $ $ $ $ Yes Yes No No

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? 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? 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)? If "Yes," attach a schedule 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.

6

Yes

No

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 63768Z

Form

8594

(Rev. 2-2006)

Form 8594 (Rev. 2-2006)

Part III
7

Page 2 Supplemental Statement--Complete only if amending an original statement or previously filed supplemental statement because of an increase or decrease in consideration. See instructions.

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. 2-2006)