Federal Individual Report of Net 965 Tax Liability

Individual Report of Net 965 Tax Liability
Form 965-A (Rev. January 2021)
Form

965-A

Individual Report of Net 965 Tax Liability

(Rev. January 2021)
Department of the Treasury
Internal Revenue Service

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Check this box if this is an amended report

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OMB No. 1545-0074

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Taxable year of reporting

(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
8

2017
2018
2019
2020

(f)
Net 965 Tax Liability
eligible for installment payment election
(subtract column (e) from column (d),
see instructions)

(g)
Installment
Election
Made
Yes

No

(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

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8

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4
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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

1
2
3
4
5
6
7
8

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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)

1
2
3
4
5
6
7
8

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Identifying number

Name of taxpayer with a net 965 tax liability

Part I

Attachment
Sequence No. 76A

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

(b)
Paid for Year 1

(c)
Paid for Year 2

(d)
Paid for Year 3

(e)
Paid for Year 4

1
2
3
4
5
6
7
8

2017
2018
2019
2020

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

(f)
Paid for Year 5

Cat. No. 71277H

Form 965-A (Rev. 1-2021)

Page 2

Form 965-A (Rev. 1-2021)

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

(j)
Net 965 Tax Liability Remaining Unpaid
(see instructions)

(i)
Paid for Year 8

(k)
Net 965 Tax Liability
Paid for the Reporting Year

1
2
3
4
5
6
7
8

1
2
3
4
5
6
7
8

Totals .

Part III

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Total
2

Total
3

Total
4

Total

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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
(a)
S Corporation Name

Year
of
965(a)
Inclusion

1

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(c)
Taxpayer’s Net Tax Liability
with only 965 amounts
from this S Corporation
(see instructions)

(b)
S Corporation
Tax Identification
Number

(e)
(d)
Net 965 Tax Liability
Taxpayer’s Net Tax Liability
related to 965 amounts from
without 965 amounts
this S Corporation (subtract
(see instructions)
column (d) from column (c))

(f)
Deferral
Election
Made
Yes
No

(g)
Deferred Net 965 Tax Liability
(if column (f) is “Yes,” enter
amount from column (e))

2017

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2018

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2019

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2020

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Form 965-A (Rev. 1-2021)

Page 3

Form 965-A (Rev. 1-2021)

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

1
2
3
4
5
6
7
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9
10

1
2
3
4
5
6
7
8
9
10

(g)
Deferred 965 Net Tax Liability
Transferred (Out) or
Transferred In by Agreement, if any
(see instructions)

(f)
Net 965 Tax Liability
Triggered
(see instructions)

(e)
Reserved for Future Use

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

(h)
Tax Identification Number
of Transferee or Transferor

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(i)
Deferred Net Tax Liability
at the end of this Reporting Year
(add columns (d), (f), and (g))
(see instructions)

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6
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10
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Form 965-A (Rev. 1-2021)