EFTA01222808.pdf

Asset Acquisition Statement Form8594 (Rev. December 2012) Under Section 1060 OMB No. 1545-1021 Attachment department Ofthe Treasury la. Attach to your income tax return. internal Revenue SIM/ILO P. Information about Form 8594 and its separate instructions is at www.irs.gov/form8594 Sequence No. 169 Name as shown on return Identifying number as shown on rattan Check the box that identifies you: El Purchaser El Seller Part I General Information 1 Name of other party to the transaction Other party's identifying number Address (number, street, and room or suite no.) City or town, state, and ZIP code 2 Date of sate 3 Total sales price (consideration) Part II Original Statement of Assets Transferred 4 Assets Aggregate fair market value (actual amount for Class 0 Allocation of sales price Class I $ $ Class II $ $ Class III $ $ Class IV $ $ Class V $ $ Class VI and VII $ $ Total $ $ 5 Did the purchaser and seller provide for an allocation of the sales pnce in the sales contract or in another written document signed by both parties? D Yes 0 No If "Yes." are the aggregate fair market values (FMV) listed for each of asset Classes I, II, III, IV, V, VI. and VII the amounts agreed upon in your sales contract or in a separate written document? 0 Yes 0 No 6 In the purchase of the group of assets (or stock), did the purchaser also purchase a license or a covenant not to compete, or enter into a lease agreement, employment contract, management contract, or similar arrangement with the seller (or managers, directors, owners, or employees of the seller)? EI Yes ❑ No If "Yes." attach a statement that specifies (a) the type of agreement and (b) the maximum amount of consideration (not including interest) paid or to be paid under the agreement. See instructions. For Paperwork Reduction Act Notice, see separate instructions. Form 8594 (Rev. 12-2012) EFTA01222808 Form 8594 (Rev. 12-2012) Page 2 Part III Supplemental Statement—Complete only if amending an original statement or previously filed supplemental statement because of an increase or decrease in consideration. See instructions. 7 Tax year and tax return form number with which the original Form 8594 and any supplemental statements were filed. 8 Assets Allocation of sales price as previously reported Increase or (decrease) Redetermined allocation of sales price Class I $ $ $ Class II $ $ $ Class III $ $ $ Class IV $ $ $ Class V $ $ $ Class VI and VII $ $ $ Total $ $ 9 Reason(s) for increase or decrease. Attach additional sheets if more space is needed. Form 8594 (Rev. 12-2012) EFTA01222809