Qualified Subchapter S Subsidiary Election
Form   8869                                                                                                                                                OMB No. 1545-0123
(Rev. December 2020)
Department of the Treasury                     (Under section 1361(b)(3) of the Internal Revenue Code) 
Internal Revenue Service    ▶ Go to www.irs.gov/Form8869 for instructions and the latest information.
Part I        Parent S Corporation Making the Election 
1a   Name of parent                                                                                                            2   Employer identification number (EIN) 

b   Number, street, and room or suite no. If a P.O. box, see instructions.                                                     3   Tax year ending (month and day) 

c   City or town, state or province, country, and ZIP or foreign postal code                                                   4   Service center where last return was filed 

5     Name and title of officer or legal representative whom the IRS may call for more information                             6   Telephone number of officer or legal  
                                                                                                                                   representative
Part II       Subsidiary Corporation for Which Election is Made (For additional subsidiaries, see instructions.) 
7a   Name of subsidiary                                                                                                        8   EIN (if any) 

b   Number, street, and room or suite no. If a P.O. box, see instructions.                                                     9   Date incorporated 

c   City or town, state or province, country, and ZIP or foreign postal code                                                   10  State of incorporation 

11    Date election is to take effect (month, day, year) (see instructions) . . . . .          . .      . .  .   .    .   .  . .   . .   .      .  ▶
12    Did the subsidiary previously file a federal income tax return? If “Yes,” complete lines 13a, 13b, and 13c .    .   .  . .   . .   .      .    ▶       Yes       No 
13a Service center where last return was filed 13b Tax year ending date of last                                       13c Check type of return filed:        Form 1120 
                                                    return (month, day, year) ▶                                              Form 1120-S               Other ▶
14    Is this election being made in combination with a section 368(a)(1)(F) reorganization described in Rev. Rul. 2008-18, where the subsidiary was 
      an S corporation immediately before the election and a newly formed holding company will be the subsidiary’s parent?     .   . .   .      .        ▶   Yes       No 
15    Was the subsidiary’s last return filed as part of a consolidated return? If “Yes,” complete lines 16a, 16b, and 16c  . . .   . .   .      .      ▶     Yes       No 
16a Name of common parent                      16b  EIN of common parent                                              16c Service center where consolidated return was filed 

Under penalties of perjury, I declare that I have examined this election, including accompanying statements, and to the best of my knowledge and belief, it is true, correct, 
and complete. 
Signature of officer   
of parent corporation ▶                                                           Title ▶                                            Date ▶
For Paperwork Reduction Act Notice, see separate instructions.                                            Cat. No. 28755K                             Form 8869 (Rev. 12-2020)