Form 966 Corporate Dissolution or Liquidation

(Rev. August 1998) OMB No. 1545-0041 (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 1120-L

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 of 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

The time needed to complete and file this form will vary depending

on individual circumstances. The estimated average time is:

File Form 966 with the Internal Revenue Service Center where the Recordkeeping 5 hr., 1 min.

corporation is required to file its income tax return. Learning about the law or the form 6 min.

Distribution of property. A corporation must recognize gain or loss Preparing and sending the form to the IRS 11 min.

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 simpler, we would be

happy to hear from you. You can write to the Tax Forms Committee,

Western Area Distribution Center, Rancho Cordova, CA 95743-0001.

DO NOT send the tax form to this office. Instead, see When and

where to file on this page.

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 it 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. 8-98)

©

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.

You are not required to provide the information requested by a

form or its instructions that is subject to the Paperwork Work

Reduction Act unless the form displays a valid OMB control number.

Books and records relating to a form or its instructions must be

retained as long as their content may become material in the

administration of any Internal Revenue law. Generally, tax returns and

return information are confidential, as required by section 6103.

that you are complying with these laws and to allow us to figure and

collect the right amount of tax.