Form 8594 (2012) - Asset Acquisition Statement
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28594
Asset Acquisition Statement
OMB No. 1545-1021
Form
Under Section 1060
(Rev. December 2012)
Attachment
Attach to your income tax return.
▶
169
Department of the Treasury
Sequence No.
Information about Form 8594 and its separate instructions is at
▶
Internal Revenue Service
Name as shown on return
Identifying number as shown on return
Check the box that identifies you:
Purchaser
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
3
Date of sale
Total sales price (consideration)
Part II
Original Statement of Assets Transferred
4
Assets
Aggregate fair market value (actual amount for Class I)
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 price in the sales contract or in another
written document signed by both parties? .
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Yes
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? .
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Yes
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)? .
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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.
8594
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 63768Z
Form
(Rev. 12-2012)
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