OMB No. 1545-1021
Asset Acquisition Statement
8594Form
Under Section 1060
(Rev. October 2002)
Department of the Treasury
Internal Revenue Service
Attachment
Sequence No.
61
Attach to your income tax return.
Name as shown on return
Seller
Check the box that identifies you:
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
Form 8594 (Rev. 10-2002)For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 63768Z
Purchaser
Identifying number as shown on return
General Information
2 Date of sale 3 Total sales price (consideration)
Part I
Part II Assets Transferred—All filers of an original statement must complete.
Allocation of sales priceAggregate fair market value (actual amount for Class I)Assets
4
$$Class I
$$Class II
Class V $$
Total $
Did the purchaser and seller provide for an allocation of the sales price in the sales contract or in another
written document signed by both parties?
5
NoYes
If “Yes,” are the aggregate fair market values (FMV) listed for each of asset Classes I, II, III, IV, V, VI, and
VII the amounts agreed upon in your sales contract or in a separate written document?
Yes No
In the purchase of the group of assets (or stock), did the purchaser also purchase a license or a covenant
not to compete, or enter into a lease agreement, employment contract, management contract, or similar
arrangement with the seller (or managers, directors, owners, or employees of the seller)?
6
NoYes
If “Yes,” attach a schedule that specifies (a) the type of agreement and (b) the maximum amount of
consideration (not including interest) paid or to be paid under the agreement. See instructions.
$
$$Class IV
$$Class VI and VII
$$Class III
See separate instructions.
Page 2Form 8594 (Rev. 10-2002)
Supplemental StatementComplete only if amending an original statement or previously filed
supplemental statement because of an increase or decrease in consideration.
Allocation of sales price as previously reported Redetermined allocation of sales priceIncrease or (decrease)
Assets
8
Class I $$$
Class II $$$
Class III $$$
$Total
Reason(s) for increase or decrease. Attach additional sheets if more space is needed.
7
9
Tax year and tax return form number with which the original Form 8594 and any supplemental statements were filed.
Class VI and VII $$$
Class IV $$$
Class V $$$
Form 8594 (Rev. 10-2002)
$
Part III