SCHEDULE A 
(Form 8975)                                                          Tax Jurisdiction and Constituent Entity Information
(June 2017)                             For reporting period beginning                                          , 20          , and ending                                 , 20                      OMB No. 1545-2272
Department of the Treasury                   ▶ A separate Schedule A (Form 8975) is to be completed for each tax jurisdiction of the multinational enterprise group. 
Internal Revenue Service                         ▶ Information about Schedule A (Form 8975) and its separate instructions is at www.irs.gov/form8975.
Name of the reporting entity                                                                                                                                                                      EIN

Part I            Tax Jurisdiction Information. All financial amounts must be stated in U.S. dollars. See instructions.
Tax jurisdiction

                            1. Revenues                              2. Profit (loss) before 3. Income tax paid      4. Income tax      5. Stated capital      6. Accumulated       7. Number of     8. Tangible assets 
    (a)                        (b)                         (c)          income tax           (on cash basis)    accrued—current                                   earnings          employees        other than cash and 
    Unrelated     party     Related     party              Total                                                          year                                                                            cash equivalents     

Part II           Constituent Entity Information 
                       1. Constituent entities resident in                         2. TIN            3. Tax jurisdiction of                                       4. Main business activities
                            the tax jurisdiction                                                             organization or 
                                                                                                             incorporation if                                                                (b) 
                                                                                                     different from tax                    (a) 
                                                                                                             jurisdiction of            Activity     code            If you entered the code for “Other,” describe the 
                                                                                                                residence                                                           business activity

For Paperwork Reduction Act Notice, see separate instructions.                                                            Cat. No. 69310N                                           Schedule A (Form 8975) (6-2017)

Schedule A (Form 8975) (6-2017)                                                                                                                                                          Page 2
Part II  Constituent Entity Information (continued)
         1. Constituent entities resident in       2. TIN                             3. Tax jurisdiction of                            4. Main business activities
            the tax jurisdiction                                                          organization or 
                                                                                          incorporation if                                                         (b) 
                                                                                      different from tax          (a) 
                                                                                          jurisdiction of         Activity     code        If you entered the code for “Other,” describe the 
                                                                                          residence                                                       business activity

Part III Additional Information
Enter any additional information related to the information reported in Part I and II.

                                                                                                                                                          Schedule A (Form 8975) (6-2017)