Country-by-Country Report
Form  8975
(June 2017)                 For reporting period beginning                     , 20  , and ending                         , 20  OMB No. 1545-2272
Department of the Treasury         ▶ Information about Form 8975 and its separate instructions is at www.irs.gov/form8975.
Internal Revenue Service 
If this is an amended report, check here

Enter the number of Schedules A (Form 8975) attached to this Form 8975   ▶
Part I      Identification of Filer
1a    Name of the reporting entity                                                   1b Reporting role code               1c EIN

2     Number, street, and room or suite no. (if P.O. box, see instructions)

3a    City or town                                             3b  State or province                 3c  Country, and ZIP or foreign postal code

Part II     Additional Information
Enter any additional information related to the multinational enterprise group.

For Paperwork Reduction Act Notice, see separate instructions.                       Cat. No. 37798N                            Form 8975 (6-2017)

Form 8975 (6-2017)                                  Page 2
Part II Additional Information (continued)

                                          Form 8975 (6-2017)