Form 966 Corporate Dissolution or Liquidation

OMB No. 1545-0041

(Rev. January 1993) Expires 1-31-96 (Required under section 6043(a) of the Internal Revenue Code) Department of the Treasury

Internal Revenue Service

Name of corporation Employer identification number

Number, street, and room or suite no. (If a P.O. box number, see instructions below.) Check type of return

1120 1120L

City or town, state, and ZIP code 1120-IC-DISC 1120S

Please type or print

Other ©

1 Date incorporated 2 Place incorporated 3 Type of liquidation

Complete Partial

5 7b

Common Preferred

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

9 Date(s) of any amendments to plan of dissolution

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

11 If this return concerns an amendment or supplement to a resolution or plan, enter the date

the previous Form 966 was filed

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

Under penalties of perjury, I declare that I 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 Title Date

Instructions

Paperwork Reduction Act Notice.—We ask for the information

on this form to carry out the Internal Revenue laws of the United

States. You are required to give us the information. We need it

to ensure that you are complying with these laws and to allow

us to figure and collect the right amount of tax.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average

time is:

Recordkeeping 5 hr., 1 min.

File Form 966 with the Internal Revenue Service Center where

the corporation is required to file its income tax return.

Learning about the law or the form 6 min.

Preparing and sending the form to the IRS 11 min.

Distribution of Property.—A corporation must recognize gain or

loss on the distribution of its assets in the complete liquidation

of its stock. For purposes of determining gain or loss, the

distributed assets are valued at fair market value. Exceptions to

this rule apply to liquidation of a subsidiary and to a distribution

that is made pursuant to a plan of reorganization.

If you have comments concerning the accuracy of these time

estimates or suggestions for making this form more simple, we

would be happy to hear from you. You can write to both the

Internal Revenue Service, Washington, DC 20224, Attention:

IRS Reports Clearance Officer, T:FP; and the Office of

Management and Budget, Paperwork Reduction Project

(1545-0041), Washington, DC 20503. DO NOT send the tax form

to either of these offices. Instead, see When and Where To File

below.

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 of a

corporation.

Who Must File.—A corporation must file Form 966 if its adopts

a resolution or plan to dissolve the corporation or liquidate any

of its stock. Exempt organizations are not required to file Form

966. These organizations should see the Instructions for Form

990 or 990-PF.

Form 966 (Rev. 1-93)

©

Service Center where corporation filed

its immediately preceding tax return

Last month, day, and year of

immediately preceding tax year

Last month, day, and year of

final tax year

Was corporation’s final tax return

filed as part of a consolidated

income tax return? If “Yes,”

complete 7c, 7d, and 7e.

Name of common parent Employer Identification Number

of Common Parent

Service Center where

consolidated return was filed

Address.—Include the suite, room, or other unit number after

the street address. If mail is not delivered to the street address

and the corporation has a P.O. box, enter the box number

instead of the street address.

6 7a

7c 7d 7e

Yes No

Cat. No. 17053B

Date resolution or plan of complete

or partial liquidation was adopted

4

When and Where 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 another Form 966

within 30 days after the amendment or supplement is adopted.

The additional form will be sufficient if the date the earlier form

was filed is entered on line 11 and a certified copy of the

amendment or supplement is attached. Include all information

required by Form 966 that was not given in the earlier form.