Form 8883 

(Rev. October 2017)

Department of the Treasury 

Internal Revenue Service 

Asset Allocation Statement 

Under Section 338

▶ Attach to your income tax return.

▶ Go to www.irs.gov/Form8883 for instructions and the latest information.

OMB No. 1545-0123

Part I Filer’s Identifying Information

1a Name as shown on return 1b Identifying number as shown on return

1c Check applicable box (see instructions):

Old target New target

1d Was a valid and timely Form 8023 filed? . . . . Yes No

If "Yes," enter the date filed ▶

Part II Other Party’s Identifying Information

2a Name of other party to the transaction 2b Other party’s identifying number

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

City or town, state, and ZIP code

Part III Target Corporation’s Identifying Information

3a Name and address of target corporation 3b Employer identification number

3c State or country of incorporation

Part IV General Information

4a Acquisition date 4b What percentage of target corporation stock was 

purchased:

(i) During the 12-month acquisition period? %

(ii) On the acquisition date? . . . . . %

5a Stock price

$

5b Acquisition costs/Selling costs

$

5c Target liabilities

$

5d AGUB/ADSP

$

Yes No

6 Was the filer listed in Part I, above, a member of an affiliated group of corporations before the acquisition date? .

7 Was the target corporation a member of an affiliated group before the acquisition date? . . . . . . . . .

8 Is the target corporation or any target affiliate:

a A controlled foreign corporation? If “No,” check here if it was a CFC at any time during the preceding 5 years ▶

b A foreign corporation with income, gain, or loss effectively connected with the conduct of a trade or business

within the United States (including U.S. real property interests)? . . . . . . . . . . . . . . . . .

c A qualifying foreign target under Regulations section 1.338-2(e)(1)(iii)? . . . . . . . . . . . . . . .

d A corporation electing under section 1504(d) or section 953(d)? . . . . . . . . . . . . . . . . .

e A domestic international sales corporation (DISC)? . . . . . . . . . . . . . . . . . . . . .

f A passive foreign investment company (PFIC)? . . . . . . . . . . . . . . . . . . . . . .

g If the answer to item 8f is “Yes,” is the PFIC a pedigreed qualified electing fund? . . . . . . . . . . .

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 33707Y Form 8883 (Rev. 10-2017)
Form 8883 (Rev. 10-2017) Page 2 

Part V Original Statement of Assets Transferred

9 Assets Aggregate fair market value (actual amount for Class I) Allocation of AGUB or ADSP

Class I $ $

Class II $ $

Class III $ $

Class IV $ $

Class V $ $

Class VI and VII $ $

Total $ $

Part VI Supplemental Statement of Assets Transferred—Complete if amending an original statement or previously filed 

supplemental statement because of an increase or decrease in AGUB or ADSP.

10 Enter the tax year and tax return form number with which the original Form 8023 or Form 8883 and any supplemental 

statements were filed. ▶

11 Assets Allocation of sales price as previously reported Increase or (decrease) Redetermined allocation of AGUB or ADSP

Class I $ $ $

Class II $ $ $

Class III $ $ $

Class IV $ $ $

Class V $ $ $

Class VI and VII $ $ $

Total $ $

12 Reason(s) for increase or decrease. Attach additional sheets if more space is needed.

Form 8883 (Rev. 10-2017)