rom 966

(Rev. June 1987)

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 6-30-90

E} Name of corporation Employer identification number
a
5 —_—
g| Address (Number and street) Check type of return
$
< O 1120 O 11201
8] City or town, state, and ZIP code O 11201¢-01Is¢ 6 11208
a 1 Other >
1 Date incorporated 2 Place incorporated 3 Type of liquidation
(1_Complete (Partial
4 Internal Revenue Service Service Center Tax year ending
Center where last income
tax return was filed and Month Year
tax year covered
5 Date of adoption of resolution | 6 Tax year of final return .
lan of dissolution,
complete or partial Tiguidation Was final return filed with a parent corporation (consolidated return)? -O Yes O No
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 1s to be dissolved or liquidated,

10 If this return concerns an amendment or supplement to toa resolution or 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.

U Signature of officer

Date Ving

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 1s to be
dissolved or if any of its stock ts to be liquidated. Exempt
organizations are not required to file Form 966. These
organizations should see the instructions for Form 990 or 990-PF.
When To File.—File Form 966 within 30 days after the resolution
or plan 1s adopted to dissolve the corporation or liquidate any of its
stock. If the resolution or plan is amended or supplemented after
Form 966 1s 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,

Section 333 Repealed

Section 333 has been repealed by the Tax Reform Act of 1986.
Transitional rules, however, allow small businesses to liquidate
under section 333. In addition, corporations will have to include a
portion of the gain from the liquidation in income. For more
information, see sections 631(e) and 633 of the Tax Reform Act
of 1986, and Form 964-A, Computation of Gain or Loss
Recognized by Corporations on Section 333 Liquidations.

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.

Form 966 (Rev. 6-87)