Form 965-A

(January 2019)

Individual Report of Net 965 Tax Liability

Department of the Treasury 

Internal Revenue Service

▶ Go to www.irs.gov/Form965A for instructions and the latest information.

OMB No. 1545-0074

Check this box if this is an amended report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Name of taxpayer with a net 965 tax liability Identifying number Taxable year of reporting

Part I Report of Net 965 Tax Liability and Election To Pay in Installments 

(a) 

Year of Section 965(a) 

Inclusion, Liability Assumed, 

or Liability Triggering Event 

(see instructions)

(b)

Taxpayer’s Net Tax Liability 

with all 

965 amounts 

(see instructions)

(c)

Taxpayer’s Net Tax Liability 

without 

965 amounts 

(see instructions)

(d)

Net 965 Tax Liability 

(subtract column (c) from column (b))

(e)

S Corporation Shareholder Total 

Deferred Net 965 Tax Liability 

(line total from Part III, column (g), 

see instructions)

1

2

3

4

5

6

7

(f)

Net 965 Tax Liability 

eligible for installment payment election 

(subtract column (e) from column (d), 

see instructions)

(g)

Installment 

Election 

Made

(h)

Net 965 Tax Liability 

to be paid in full for Year 1 

(if column (g) is “No,” enter amount 

from column (f))

(i) 

Net 965 Tax Liability 

to be paid in installments 

(if column (g) is “Yes,” enter amount 

from column (f) and see instructions) 

(j) 

Net 965 Tax Liability Transferred (Out), 

Transferred In, or 

Subsequent Adjustments, 

if any (see instructions)

(k) 

Tax Identification Number 

of buyer/transferee or 

seller/transferor

 Yes No 

1

2

3

4

5

6

7

Part II Record of Amount of Net 965 Tax Liability Paid by the Taxpayer (see instructions)

(a) 

Year of 

Section 965(a) Inclusion, 

Liability Assumed, or 

Triggering Event

(b)

Paid for Year 1

(c)

Paid for Year 2

(d)

Paid for Year 3

(e)

Paid for Year 4

(f)

Paid for Year 5

1

2

3

4

5

6

7

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 71277H Form 965-A (1-2019)
Form 965-A (1-2019) Page 2

Part II Record of Amount of Net 965 Tax Liability Paid by the Taxpayer (continued)

(g)

Paid for Year 6

(h)

Paid for Year 7

(i)

Paid for Year 8

(j)

Net 965 Tax Liability Remaining Unpaid 

(see instructions)

(k)

Net 965 Tax Liability 

Paid for the Reporting Year

1

2

3

4

5

6

7

Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Part III S Corporation Shareholder: Report of Calculation of Net 965 Tax Liability Related to 965 Amounts Allocated From an S Corporation and 

Election To Defer Such Net 965 Tax Liability

Year 

of 

965(a) 

Inclusion

(a)

S Corporation Name

(b)

S Corporation 

Tax Identification 

Number

(c)

Taxpayer’s Net Tax Liability 

with only 965 amounts 

from this S Corporation 

(see instructions)

(d)

Taxpayer’s Net Tax Liability 

without 965 amounts 

(see instructions)

(e)

Net 965 Tax Liability 

related to 965 amounts from 

this S Corporation (subtract 

column (d) from column (c))

(f)

Deferral 

Election 

Made

(g)

Deferred Net 965 Tax Liability 

(if column (f) is “Yes,” enter 

amount from column (e))

 Yes No 

1 2017 (i)

 (ii)

 (iii)

 (iv)

 (v)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

▶ 

2 2018 (i)

 (ii)

 (iii)

 (iv)

 (v)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Form 965-A (1-2019)
Form 965-A (1-2019) Page 3

Part IV Annual Report of Deferred Net 965 Tax Liability Related to 965 Amounts Allocated From S Corporations 

(required every year until the liability is fully paid)

(a) 

Election or 

Transfer Year

(b)

S Corporation Name

(c)

S Corporation 

Tax Identification Number

(d)

Beginning Deferred 

Net 965 Tax Liability 

(see instructions)

1

2

3

4

5

6

7

8

9

10

( )

( )

( )

( )

( )

( )

( )

 ( )

( )

( )

(e)

Reserved for Future Use

(f)

Net 965 Tax Liability 

Triggered 

(see instructions)

(g)

Deferred 965 Net Tax Liability 

Transferred (Out) or 

Transferred In by Agreement, if any 

(see instructions)

(h)

Tax Identification Number 

of Transferee or Transferor

(i)

Deferred Net Tax Liability 

at the end of this Reporting Year 

(add columns (d), (e), (f), and (g)) 

(see instructions)

1

2

3

4

5

6

7

8

9

10

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

If more lines are needed for any Part on this form, attach additional sheets.

Form 965-A (1-2019)