Asset Acquisition Statement                                                        OMB No. 1545-1021 
Form  8594                                               Under Section 1060
(Rev. December 2012)                                   ▶ Attach to your income tax return.                                      Attachment  
Department of the Treasury    ▶ Information about Form 8594 and its separate instructions is at www.irs.gov/form8594            Sequence No.  169 
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     Date of sale                                                                    3 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? .      .  . . . . . . .                  . . . . . . . .       . .         . . .      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? .           . .       . .         . . .      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)?  .            . .         . . .      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. 

For Paperwork Reduction Act Notice, see separate instructions.                                Cat. No. 63768Z                   Form 8594 (Rev. 12-2012) 

Form 8594 (Rev. 12-2012)                                                                                            Page  2 
Part III  Supplemental Statement—Complete only if amending an original statement or previously filed supplemental 
          statement because of an increase or decrease in consideration. See instructions. 
7 Tax year and tax return form number with which the original Form 8594 and any supplemental statements were filed. 

8      Assets            Allocation of sales price as previously reported   Increase or (decrease)   Redetermined allocation of sales price 

Class I          $                                                        $                        $ 

Class II         $                                                        $                        $ 

Class III        $                                                        $                        $ 

Class IV         $                                                        $                        $ 

Class V          $                                                        $                        $ 

Class VI and VII $                                                        $                        $ 

Total            $                                                                                 $ 
9 Reason(s) for increase or decrease. Attach additional sheets if more space is needed. 

                                                                                                     Form 8594 (Rev. 12-2012)