Federal Asset Allocation Statement Under Section 338

Asset Allocation Statement Under Section 338
Form 8883 (Rev. October 2017)
8883

Form
(Rev. October 2017)

Department of the Treasury
Internal Revenue Service

Part I

Asset Allocation Statement
Under Section 338

Filer’s Identifying Information

1a Name as shown on return

1c

1b Identifying number as shown on return

Check applicable box (see instructions):
Old target
New target

Part II

OMB No. 1545-0123

Attach to your income tax return.
▶ Go to www.irs.gov/Form8883 for instructions and the latest information.
▶

1d Was a valid and timely Form 8023 filed? .
If "Yes," enter the date filed ▶

.

.

.

Yes

No

Other Party’s Identifying Information

2a Name of other party to the transaction

2b Other party’s identifying number

Address (number, street, and room or suite no.)

City or town, state, and ZIP code

Part III

Target Corporation’s Identifying Information

3a Name and address of target corporation

3b Employer identification number

3c State or country of incorporation

Part IV

General Information

4a Acquisition date

5a Stock price

5b Acquisition costs/Selling costs

4b What percentage of target corporation stock was
purchased:
(i) During the 12-month acquisition period?
(ii) On the acquisition date? . . . . .
5c Target liabilities
5d AGUB/ADSP

$

$

$

%
%

$
Yes No

6
7
8

Was the filer listed in Part I, above, a member of an affiliated group of corporations before the acquisition date? .
Was the target corporation a member of an affiliated group before the acquisition date? . . . . . . . . .
Is the target corporation or any target affiliate:
a A controlled foreign corporation? If “No,” check here if it was a CFC at any time during the preceding 5 years ▶
b A foreign corporation with income, gain, or loss effectively connected with the conduct of a trade or business
within the United States (including U.S. real property interests)? . . . . . . . . . . . . . . . . .
c A qualifying foreign target under Regulations section 1.338-2(e)(1)(iii)? . . . . . . . . . . . . . . .
d A corporation electing under section 1504(d) or section 953(d)? . . . . . . . . . . . . . . . . .
e A domestic international sales corporation (DISC)? . . . . . . . . . . . . . . . . . . . . .
f A passive foreign investment company (PFIC)? . . . . . . . . . . . . . . . . . . . . . .
g If the answer to item 8f is “Yes,” is the PFIC a pedigreed qualified electing fund? . . . . . . . . . . .

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 33707Y

Form 8883 (Rev. 10-2017)

Page 2

Form 8883 (Rev. 10-2017)

Part V
9

Original Statement of Assets Transferred

Assets

Aggregate fair market value (actual amount for Class I)

Allocation of AGUB or ADSP

Class I

$

$

Class II

$

$

Class III

$

$

Class IV

$

$

Class V

$

$

Class VI and VII

$

$

Total

$

$

Part VI

Supplemental Statement of Assets Transferred—Complete if amending an original statement or previously filed
supplemental statement because of an increase or decrease in AGUB or ADSP.

10

Enter the tax year and tax return form number with which the original Form 8023 or Form 8883 and any supplemental
statements were filed. ▶

11

Assets

Allocation of sales price as previously reported

Increase or (decrease)

Redetermined allocation of AGUB or ADSP

Class I

$

$

$

Class II

$

$

$

Class III

$

$

$

Class IV

$

$

$

Class V

$

$

$

Class VI and VII

$

$

$

Total
$
12
Reason(s) for increase or decrease. Attach additional sheets if more space is needed.

$

Form 8883 (Rev. 10-2017)