rom 966

(Rev. December 1981)

Department of the Treasury
Internal Revenue Service

Corporate Dissolution or Liquidation
(Required under Section 6043(a) of the Internal Revenue Code)

‘OMB No. 1545-0041

Expires 11-30-84

Name of corporation

Employer identification number

Address (Number and street)

“Check type of return [] 1120

Please type or print

[J 120 vise Fy 22208
City or town, State and ZIP code [] 120m [J 20s
[] Other >
1 Date incorporated 2 Place incorporated 3 Type of liquidation
im} Complete Oo Partial

4 Internal Revenue Service

Service Center

Tax year ending

Center where last income Month Year
tax return was filed and
tax year covered
5 Date of: adoption of resolu- | 6 Tax year of final return. 6 we ew ee ee
tion or plan of dissolution, or Was final return filed with a parent corporation (consolidated return)? . Cl Yes [] No

complete or partial liquidation
If “Yes,” enter:

Name of parent corporation p>
Employer identification number p>

IRS Center where consolidated return was filed p>

7 Total number of shares outstanding at time of adoption of plan or liquidation . . . +» + - + + + =

Common Preferred

9 Section of the Code under which
the corporation is to be dis-
solved or liquidated

@ Dates of any amendments to
plan of dissolution

10 If this return concerns an amendment or supplement to a resolution or plan

for which a return was filed, give the date filed

11. Liquidation Within One Calendar Month.—Please submit the statements.
listed below for a domestic corporation if any of the shareholders claim
the benefit of section 333 and if the liquidation plan provides for (1) a
distribution to cancel or redeem all the corporation's capital stock and (2)
transfer of all the corporation's property within 1 calendar month under
section 333.

(@) A description of the voting power of each class of stock.

(b) A list of all shareholders as of the date the liquidation plan was
adopted. Show the number of shares each shareholder owns in each class
of stock, the certificate numbers, and the number of votes each was en-
titled to cast concerning the adoption of the liquidation plan.

(c) A list of all corporate shareholders as of January 1, 1954. Show the
number of shares each one owned in each class of stock, the certificate
numbers, and the number of votes each was entitled to cast concerning the
adoption of the liquidation plan. Also explain all changes in corporate
ownership of stock after December 31, 1953, through the date the liquida-
tion plan was adopted.

(d) A computation, as described in Regulation section 1.6043-2(b), of
accumulated earnings and profits. Follow the format in Revenue Procedure
75-17, 1975-1 C.B. 677, and include all income and expenses accrued
up to the date all property is transferred.

Attach a certified copy of the resolution or plan, together with all amendments or supplements not previously filed.

Under penalties of perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and

belief it is true, correct, and complete.

Dima of officer

Date Diaz

Instructions

Paperwork Reduction Act Notice.—The Paperwork Reduction
Act of 1980 says we must tell you why we are collecting this in-
formation, how we will use it, and whether you have to give it to
us. We ask for the information to carry out the Internal Revenue
laws of the United States. We need it to ensure that you are com-
plying with these laws and to allow us to figure and collect the
right amount of tax. You are required to give us this information.

1. Who must file.—A corporation files Form 966 if it is to be
dissolved or if any of its stock is to be liquidated. Exempt or-
ganizations are not required to file Form 966. These organizations
should see the instructions for Form 990 or 990—-PF.

Shareholders electing to be covered under Code section 333
must also file Form 964 within 30 days after the date of adop-
tion of the plan of liquidation.

2. When to file.—File Form 966 within 30 days after the reso-
lution or plan is adopted to dissolve the corporation or liquidate

any of its stock. If the resolution or plan is amended or supple-
mented after Form 966 is filed, file an additional Form 966 within
30 days after the amendment or supplement is adopted. The ad-
ditional form will be sufficient if you show the date the earlier
form was filed and attach a certified copy of the amendment or
supplement and all other information required by Form 966 and
not given in the earlier form.

3. Where to file.—File Form 966 with the Internal Revenue
Service Center where the corporation is required to file its income
tax return.

4. Signature.—The return must be signed and dated by the
president, vice president, treasurer, assistant treasurer, chief ac-
counting officer, or any other corporate officer (such as tax
officer) authorized to sign. A receiver, trustee, or assignee must
sign and date any return required to be filed on behalf of a
corporation.

#7U.S. Government Printing Offic

Form 966 (Rev. 12-81)

e2—361-904/1