SCHEDULE A
(Form 8975)
(June 2017)
Department of the Treasury
Internal Revenue Service
Tax Jurisdiction and Constituent Entity Information
For reporting period beginning , 20 , and ending , 20
A separate Schedule A (Form 8975) is to be completed for each tax jurisdiction of the multinational enterprise group.
Information about Schedule A (Form 8975) and its separate instructions is at www.irs.gov/form8975.
OMB No. 1545-2272
Name of the reporting entity EIN
Part I
Tax Jurisdiction Information. All financial amounts must be stated in U.S. dollars. See instructions.
Tax jurisdiction
1. Revenues
(a)
Unrelated party
(b)
Related party
(c)
Total
2. Profit (loss) before
income tax
3. Income tax paid
(on cash basis)
4. Income tax
accrued—current
year
5. Stated capital 6. Accumulated
earnings
7. Number of
employees
8. Tangible assets
other than cash and
cash equivalents
Part II Constituent Entity Information
1. Constituent entities resident in
the tax jurisdiction
2. TIN
3. Tax jurisdiction of
organization or
incorporation if
different from tax
jurisdiction of
residence
4. Main business activities
(a)
Activity code
(b)
If you entered the code for “Other,” describe the
business activity
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 69310N
Schedule A (Form 8975) (6-2017)
Schedule A (Form 8975) (6-2017)
Page 2
Part II
Constituent Entity Information (continued)
1. Constituent entities resident in
the tax jurisdiction
2. TIN
3. Tax jurisdiction of
organization or
incorporation if
different from tax
jurisdiction of
residence
4. Main business activities
(a)
Activity code
(b)
If you entered the code for “Other,” describe the
business activity
Part III Additional Information
Enter any additional information related to the information reported in Part I and II.
Schedule A (Form 8975) (6-2017)
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