rom 966

(Rev. November 1984)

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 10-31-87

=] Name of corporation Employer identification number
5
| Address (Number and street) Checktypeofreturn [1] 1120
3) O 1uzopsc = 1120
&| City or town, State and ZIP code 0 1120m 1120s
z other »
1 Date incorporated Place incorporated 3. Type of liquidation
O Complete C1 Partial

4 Internal Revenue Service Service Center Tax year ending

Center where last income Month y

tax return was filed and lon ear

tax year covered |
5 Date of adoption of resolution Tax year of final return |

or plan of dissolution, or Was final return filed with a parent corporation (consolidated return)? . O ves O No

complete or partial liquidation

If "Yes," enter:
Name of parent corporation ® ____
Employer identification number ®

IRS Center where consolidated return was filed >

7 Total number of shares outstanding at time of adoption of plan or liquidation

Common Preferred

8 Dates of any amendments to plan of dissolution.

9 Section of the Code under which the corporation is to be dissolved or liquidated.

10 if this return concerns an amendment or supplement toa resolution or plan for which a return was filed, give

the date filed.

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.

>

>

Signature of officer

Date Title

Instructions

Paperwork Reduction Act Notice.— We ask for this information
to carry out the Internal Revenue laws of the United States. We
need it to ensure that taxpayers are complying with these laws
and to allow us to figure and collect the right amount of tax. You
are required to give us this information.
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
organizations 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 adoption
of the plan of liquidation.
When to file.—File Form 966 within 30 days after the resolution

or plan is adopted to dissolve the corporation or liquidate any of its
stock. If the resolution or plan is amended or supplemented after

Form 966 is filed, file an additional Form 966 within 30 days after
the amendment or supplement is adopted. The additional 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.

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

Signature.—The return must be signed and dated by the
president, vice president, treasurer, assistant treasurer, chief
accounting 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 ofa
corporation.

Form 966 (Rev. 11-84)