PDF document
- 1 -
                                                           Affiliations Schedule 
Form   851                         For tax year ending                                        ,                          OMB No. 1545-0123 
(Rev. October 2016)                     ▶ File with each consolidated income tax return. 
Department of the Treasury        ▶ Information about Form 851 and its instructions is at www.irs.gov/form851.
Internal Revenue Service 
Name of common parent corporation                                                                       Employer identification number 

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

City or town, state, and ZIP code 

Part I  Overpayment Credits, Estimated Tax Payments, and Tax Deposits  (see instructions) 
                                                                            Employer               Portion of   
Corp.                    Name and address of corporation                identification           overpayment credits         Portion of tax   
No.                                                                          number                and estimated         deposited with   
                                                                                                    tax payments             Form 7004 
1      Common parent corporation 
       Subsidiary corporations: 
2 

3 

4 

5 

6 

7 

8 

9 

10 

      Totals  (Must equal amounts shown on the consolidated tax return.) .    . .         .  ▶
Part II Principal Business Activity, Voting Stock Information, Etc.  (see instructions) 
                                                                              Did the subsidiary   Stock holdings at beginning of year 
                                                                       PBA    make any nondividend 
Corp.                    Principal business activity (PBA)             Code     distributions?     Number    Percentage  Percentage Owned by  
No.                                                                                                of         of voting  of value   corporation 
                                                                       No.                         shares       power                   no. 
                                                                                Yes           No                                            
       Common parent corporation 
1 
       Subsidiary corporations: 
2                                                                                                                      %          % 

3                                                                                                                      %          % 

4                                                                                                                      %          % 

5                                                                                                                      %          % 

6                                                                                                                      %          % 

7                                                                                                                      %          % 

8                                                                                                                      %          % 

9                                                                                                                      %          % 

10                                                                                                                     %          % 
For Paperwork Reduction Act Notice, see instructions.                         Cat. No. 16880G                           Form 851 (Rev. 10-2016) 



- 2 -
Form 851 (Rev. 10-2016)                                                                                                               Page  2 
Part III   Changes in Stock Holdings During the Tax Year 
                                                                                                                      (b)  Shares held after   
                                                                                           (a)  Changes             changes described in   
                                                          Share- 
Corp.                   Name of corporation                holder of    Date                                               column (a) 
No.                                                       Corpora-          of  
                                                             tion No.      transaction Number of    Number of     Percentage of   Percentage of   
                                                                                       shares       shares        voting power        value 
                                                                                       acquired     disposed of 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

                                                                                                                           %                   % 

(c)    If  any  transaction  listed  above  caused  a  transfer  of  a  share  of  subsidiary  stock  (defined  to  include
       dispositions and deconsolidations), did the share's basis exceed its value at the time of the transfer? See 
       instructions .   . . . . . .         . . . . . . . .  . .      . .  .    .      . . .      . . . .   .     . .             Yes No

(d)    Did any share of subsidiary stock become worthless within the meaning of section 165 (taking into account 
       the provisions of Regulations section 1.1502-80(c)) during the taxable year? See instructions   .        . . .          Yes    No

(e)    If the equitable owners of any capital stock shown above were other than the holders of record, provide details of the changes. 

(f)    If additional stock was issued, or if any stock was retired during the year, list the dates and amounts of these transactions. 

                                                                                                                      Form 851 (Rev. 10-2016) 



- 3 -
Form 851 (Rev. 10-2016)                                                                                                       Page  3 
Part IV  Additional Stock Information  (see instructions) 
1   During the tax year, did the corporation have more than one class of stock outstanding?  . . .   . .    .             Yes No
    If “Yes,” enter the name of the corporation and list and describe each class of stock. 
Corp. 
No.                       Name of corporation                                                Class of stock 

2   During the tax year, was there any member of the consolidated group that reaffiliated within 60 months  of
    disaffiliation?  .  . . . . . . . . .     .     . . . . . . . . . .           . . .    . . . .   . .    .             Yes No
    If “Yes,” enter the name of the corporation(s) and explain the circumstances. 
Corp. 
No.                       Name of corporation                                                Explanation 

3   During the tax year, was there any arrangement in existence by which one or more persons that were not 
    members  of  the  affiliated  group  could  acquire  any  stock,  or  acquire  any  voting  power  without  acquiring 
    stock, in the corporation, other than a de minimis amount, from the corporation or another member of the 
    affiliated group?  .  . . . . . . . .     .     . . . . . . . . . .           . . .    . . . .   . .    .             Yes No
    If “Yes,” enter the name of the corporation and see the instructions for the percentages to enter in columns
    (a), (b), and (c).
                                                                                                 (b) 
Corp.                                                                 (a)                    Percentage of                (c)                
No.                       Name of corporation                                              outstanding voting             Percentage of   
                                                                Percentage of value                                       voting power
                                                                                               stock

                                                                                      %                     %                         % 

                                                                                      %                     %                         % 

                                                                                      %                     %                         % 

                                                                                      %                     %                         % 
Corp. 
No.   (d) Provide a description of any arrangement. 

                                                                                                              Form 851 (Rev. 10-2016) 



- 4 -
Form 851 (Rev. 10-2016)                                                                                                                          Page  4 
Instructions                                        Part I                                               Item (e). The term “equitable owners” of  
Section references are to the Internal Revenue      Portion of overpayment credits and                   stock means those that essentially have all  
Code unless otherwise noted.                        estimated tax payments. Enter for the                the rights to enjoy the benefits of stock  
                                                    common parent corporation and for each               ownership without actually holding the stock,  
Future Developments                                 subsidiary corporation the amount of:                for example, beneficiaries of a trust. 
For the latest information about developments       • Overpayments of tax from the prior tax year        Part IV 
related to Form 851 and its instructions, such      that each corporation elected to credit to the       Question 1. For purposes of question 1 only,  
as legislation enacted after they were              current year's tax, and                              disregard certain preferred stock as described 
published, go to www.irs.gov/form851.               • Estimated tax payments made by each                in section 1504(a)(4). 
Purpose of Form                                     corporation.                                         Question 3. The term “arrangement”  
Use Form 851 to:                                    The total must be the same as the amounts            includes, but is not limited to, phantom stock,  
1.  Identify the common parent corporation          entered on the lines for overpayments and            stock appreciation rights, an option, warrant,  
and each member of the affiliated group;            estimated tax payments on the consolidated           conversion feature, or similar arrangements. 
                                                    income tax return.                                   Item 3a. Show the percentage of the value of  
2.  Report the amount of overpayment                Tax deposited with Form 7004. Enter for the          the outstanding stock that the person(s) could 
credits, estimated tax payments, and tax            common parent the tax deposited with Form            acquire. 
deposits attributable to each corporation; and      7004, Application for Automatic Extension of         Item 3b. If the arrangement was associated  
3.  Determine that each subsidiary                  Time To File Certain Business Income Tax,            with voting stock, show the percentage of  
corporation qualifies as a member of the            Information, and Other Returns, that is              outstanding voting stock that the person(s)  
affiliated group.                                   attributable to each corporation. The total          could acquire. 
Who Must File                                       must be the same as the amount entered on            Item 3c. If the arrangement was associated  
The parent corporation must file Form 851 for       the “Tax deposited with Form 7004” line on           with the acquisition of voting power without  
itself and for corporations in the affiliated       the consolidated income tax return.                  the acquisition of the related stock, show the  
group. File Form 851 by attaching it to the         Part II                                              percentage of voting power that the person(s)  
consolidated tax return for the group.              Principal business activity (PBA) and PBA            could acquire. 
Affiliated Group                                    Code No. Enter the PBA and the PBA code              Item 3d. Give a brief description of any  
An affiliated group is one or more chains of        number for the common parent corporation             arrangement (defined above) by which a  
includible corporations connected through           and for each subsidiary corporation. Use the         person that is not a member of the affiliated  
stock ownership with a common parent                activity for the specific industry group from        group could acquire any stock, or acquire any 
corporation. See sections 1504(a) and (b). The      which the largest percentage of each                 voting power without acquiring stock, in the  
common parent must be an includible                 corporation's total receipts is based.               corporation. 
corporation and the following requirements          A list of the PBAs and code numbers is  
must be met.                                        located in the Instructions for Form 1120.           Paperwork Reduction Act Notice 
1.  The common parent must own directly             Nondividend distributions. Nondividend               We ask for the information on this form to  
stock that represents at least 80% of the total     distributions are any distributions (other than      carry out the Internal Revenue laws of the  
voting power and at least 80% of the total          stock dividends and distributions in exchange        United States. You are required to give us the  
value of the stock of at least one of the other     for stock) made to shareholders during the           information. We need it to ensure that you are 
includible corporations.                            tax year for which the consolidated tax return       complying with these laws and to allow us to  
2.  Stock that represents at least 80% of           is filed that were in excess of the                  figure and collect the right amount of tax. 
the total voting power, and at least 80% of         corporation's current and accumulated                You are not required to provide the  
the total value of the stock of each of the         earnings and profits. See sections 301 and           information requested on a form that is  
other corporations (except for the common           316 and Form 5452, Corporate Report of               subject to the Paperwork Reduction Act  
parent) must be owned directly by one or            Nondividend Distributions.                           unless the form displays a valid OMB control  
more of the other includible corporations.          Part III                                             number. Books or records relating to a form  
                                                                                                         or its instructions must be retained as long as  
For this purpose, the term “stock” generally        Question (c). For this purpose, the term             their contents may become material in the  
doesn't include any stock that:                     “transfer” includes transactions in which (1) a      administration of any Internal Revenue law.  
1.  Is nonvoting,                                   shareholder-member ceases to own a share             Generally, tax returns and return information  
2.  Is nonconvertible,                              of subsidiary stock in a transaction in which        are confidential, as required by section 6103. 
3.  Is limited and preferred as to dividends        the shareholder-member recognizes income,            The time needed to complete and file this  
and doesn't participate significantly in            gain, deduction, or loss on the stock; (2) a         form will vary depending on individual  
corporate growth, and                               shareholder-member and the subsidiary                circumstances. The estimated burden for 
4.  Has redemption and liquidation rights           cease to be members of the same                      business taxpayers filing this form is 
that don't exceed the issue price of the stock      consolidated group; and (3) a nonmember              approved under OMB control number 
(except for a reasonable redemption or              acquires the share from a member. If any type        1545-0123 and is included in the estimates 
liquidation premium).                               of transfer occurs and the share's basis would       shown in the instructions for their business 
                                                    otherwise exceed its value at the time of the 
Address                                             transfer, certain adjustments to members'            income tax return.
Include the suite, room, or other unit number       bases in shares of the subsidiary's stock and        If you have comments concerning the  
after the street address. If the post office        to the subsidiary's attributes may be required.      accuracy of these time estimates or  
does not deliver mail to the street address         See Regulations section 1.1502-36.                   suggestions for making this form simpler, we  
and the corporation has a P.O. box, show the        Question (d). If a share of subsidiary stock         would be happy to hear from you. See the  
box number instead.                                 becomes worthless within the meaning of              instructions for the tax return with which this  
                                                    section 165 (taking into account the                 form is filed. 
Corporation Numbers                                 provisions of Regulations section     
When listing information in Parts II, III, and IV,  1.1502-80(c)) during the group's taxable year, 
use the same number for the common parent           certain adjustments to shareholder-members' 
corporation and for each subsidiary                 bases in shares of the subsidiary's stock   
corporation as the number listed in Part I.         and/or to the subsidiary's attributes may be 
                                                    required. See Regulations sections 1.1502-19
                                                    (b)(1)(iv) (if the basis of the share is equal to or 
                                                    less than zero) and 1.1502-36 (if the basis of 
                                                    the share is greater than zero).






PDF file checksum: 3359758499

(Plugin #1/9.12/13.0)