Form 966
(Rev. May 1961)
US. TREASURY DEPARTMENT
Internal Revenue Service

RETURN OF INFORMATION TO BE FILED BY CORPORATIONS WITHIN 30 DAYS
AFTER ADOPTION OF RESOLUTION OR PLAN OF DISSOLUTION,
OR COMPLETE OR PARTIAL LIQUIDATION

(Under Section 6043 of the Internal Revenue Code)

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Name of corporation

Employer identification number

Number and street

Post office, county, State, country

T. Date incorporated

2. Place incorporated

3. District Director with whom last income tax | District Director
return was filed and taxable year covered

thereby

Taxable year

4. Date of adoption of resolution or plan of dissolution, or complete or partial liquidation

Common

5. Total shares outstanding ____,_

Preferred

6. Dates of any amendments to plan of dissolution

7. If this return is in respect of an amendment of or supplement to a resolution or plan pre~
viously adopted and a return has previously been filed in respect of such resolution or

Date

plan, give date such return was file:

8 LIQUIDATION WITHIN ONE CALENDAR MONTH. If
ation is a domestic corporation, and the plan of liquidation
mo ides for a distribution in complete cancellation or redemption of
all the capital stock of the corporation and for the transfer of all the
y of the corporation under the liquidation entirely within
ne calendar month pursuant to section 333, and any share-
claims the benefit of such section, then the following informa-
tion must also be submitted:

(a) A description of the voting power of each class of stock;

(b) A list of all the shareholders owning stock at the time of the

adoption of the plan of liquidation, together with the number of shares of
cach class of stock owned by each shareholder, the certificate num-
bers thereof, and the total number of votes to which entitled on the
adoption of the plan of liquidation; and

(c) A list of all corporate shareholders as of January 1, 1954, to-
gether with the number of shares of each class of stock owned by
each such shareholder, the certificate numbers thereof, the total
number of votes to which entitled on the adoption of the plan of
liquidation, and a statement of all changes in ownership of stock by
corporate shareholders between January 1, 1954, and the date of the
adoption of the plan of liquidation, both dates inclusive.

Attach hereto as a part of this return a duly certified copy of the resolution or plan, together with all amendments thereof or supple-

ments thereto, if not heretofore filed.

SIGNATURE AND

VERIFICATION

I declare under the penalties of perjury that this return (including any accompanying schedules and statements) has been made

on proper authorization, has been examined by me, and is, to the

return, made in good faith, pursuant to the requirements of section 6043 of the Internal Revenue Code and the regulations

thereunder.

best of my knowledge and belief, a true, correct, and complete
zsued

| CORPORATE

(Date)

SEAL

(Name of corporation)

(Signature of officer)

(Title)

INSTRUCTIONS

1. This form is to be used by a corporation rendering a return of
information under section 6043 of the Internal Revenue Code. Such
return shall be filed with the district director for the district in which
the income tax return of the corporation is filed, within 30 days after
the adoption ofa resolution or plan, including any amendment thereof
or supplement thereto, for or in’ respect of the dissolution of the
corporation or the liquidation of the whole or any part of its capital
stock.

All the
detail. Us

information called for by this form shall be supplied in
additional sheets, if necessary. If a return has already

been filed in respect of any resolution or plan, a return in respect of
an amendment or supplement thereto will be deemed sufficient if it
gives the date the prior return was filed and contains a duly certi-
fied copy of such amendment or supplement and all other informa-
tion required by this form which was not given in such prior return,

3. The return must be signed either by the president, vice presi-
dent, treasurer, assistant treasurer or chief accounting officer, or by
any other corporate officer (such as tax officer) who 1s authorized to
sign. A receiver, trustee, or assignee must sign any return which he
is required to file on behalf of a corporation.

RNMENT PRINTING OFFICE : 1961 0—SA3469

Form 966 (Rev. 5-61)