Individual Report of Net 965 Tax Liability
Form  965-A                                                                                                                                                                                     OMB No. 1545-0074
(Rev. January 2020)
Department of the Treasury                                    ▶ Go to www.irs.gov/Form965A for instructions and the latest information.
Internal Revenue Service
Check this box if this is an amended report           .   .   .  .         . . .  .   .        . . . .   . .        .   . . .   .  .      . .    . .   . . .      .      . .   . .    . . . .   .   .    . .            ▶
Name of taxpayer with a net 965 tax liability                                                                                                             Identifying number              Taxable year of reporting

Part I  Report of Net 965 Tax Liability and Election To Pay in Installments 
                   (a)                                (b)                                            (c)                                           (d)                                      (e) 
        Year of Section 965(a)                Taxpayer’s Net Tax Liability                 Taxpayer’s Net Tax Liability                     Net 965 Tax Liability                S Corporation Shareholder Total 
      Inclusion, Liability Assumed,               with all                                         without                         (subtract column (c) from column (b))         Deferred Net 965 Tax Liability 
      or Liability Triggering Event           965 amounts                                          965 amounts                                                                   (line total from Part III, column (g), 
        (see instructions)                    (see instructions)                                 (see instructions)                                                                     see instructions)
1                  2017                                                                                                                                                                                                  1
2                  2018                                                                                                                                                                                                  2
3                  2019                                                                                                                                                                                                  3
4                                                                                                                                                                                                                        4
5                                                                                                                                                                                                                        5
6                                                                                                                                                                                                                        6
7                                                                                                                                                                                                                        7
8                                                                                                                                                                                                                        8
                        (f)                       (g)                             (h)                                     (i)                                        (j)                          (k) 
        Net 965 Tax Liability                 Installment                  Net 965 Tax Liability                    Net 965 Tax Liability                Net 965 Tax Liability            Tax Identification Number 
   eligible for installment payment election  Election           to be paid in full for Year 1                 to be paid in installments          Transferred (Out), Transferred In,     of buyer/transferee or 
      (subtract column (e) from column (d),   Made            (if column (g) is “No,” enter amount       (if column (g) is “Yes,” enter amount     or Subsequent Adjustments, if any        seller/transferor
        see instructions)                     Yes     No                     from column   (f))          from column (f) and   see instructions)          (see instructions)                                                
1                                                                                                                                                                                                                        1
2                                                                                                                                                                                                                        2
3                                                                                                                                                                                                                        3
4                                                                                                                                                                                                                        4
5                                                                                                                                                                                                                        5
6                                                                                                                                                                                                                        6
7                                                                                                                                                                                                                        7
8                                                                                                                                                                                                                        8
Part II Record of Amount of Net 965 Tax Liability Paid by the Taxpayer (see instructions) 
                   (a) 
        Year of Section 965(a)                    (b)                                      (c)                              (d)                                   (e)                           (f) 
      Inclusion, Liability Assumed,           Paid for Year 1                     Paid for Year 2                       Paid for Year 3                  Paid for Year 4                    Paid for Year 5
        or Triggering Event
1                  2017                                                                                                                                                                                                  1
2                  2018                                                                                                                                                                                                  2
3                  2019                                                                                                                                                                                                  3
4                                                                                                                                                                                                                        4
5                                                                                                                                                                                                                        5
6                                                                                                                                                                                                                        6
7                                                                                                                                                                                                                        7
8                                                                                                                                                                                                                        8
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.                                                        Cat. No. 71277H                                     Form 965-A (Rev. 1-2020)

Form 965-A (Rev. 1-2020)                                                                                                                                                                                 Page 2
Part II     Record of Amount of Net 965 Tax Liability Paid by the Taxpayer (continued) 
                   (g)                                (h)                               (i)                                           (j)                                           (k) 
               Paid for Year 6                    Paid for Year 7                   Paid for Year 8                Net 965 Tax Liability Remaining Unpaid                   Net 965 Tax Liability 
                                                                                                                            (see instructions)                            Paid for the Reporting Year
1                                                                                                                                                                                                        1
2                                                                                                                                                                                                        2
3                                                                                                                                                                                                        3
4                                                                                                                                                                                                        4
5                                                                                                                                                                                                        5
6                                                                                                                                                                                                        6
7                                                                                                                                                                                                        7
8                                                                                                                                                                                                        8

Totals .    .  . .       . . . . . .   . . .      . . .   . .     . .   . .     . . . . .     .     .  .        ▶
Part III    S Corporation Shareholder: Report of Calculation of Net 965 Tax Liability Related to 965 Amounts Allocated From an S Corporation and 
            Election To Defer Such Net 965 Tax Liability
        Year                       (a)                              (b)                 (c)                            (d)                         (e)                      (f) 
         of                    S Corporation Name                 S Corporation   Taxpayer’s Net Tax Liability  Taxpayer’s Net Tax Liability   Net 965 Tax Liability      Deferral                   (g) 
      965(a)                                                Tax Identification    with only 965 amounts          without 965 amounts         related to 965 amounts from  Election        Deferred Net 965 Tax Liability
     Inclusion                                                    Number          from this S Corporation          (see instructions)        this S Corporation (subtract   Made          (if column (f) is “Yes,” enter 
                                                                                    (see instructions)                                       column (d) from column (c))                  amount from column (e))
                                                                                                                                                                          Yes      No                   
              
1     2017
              
Total  .    .  . .       . . . . . .   . . .      . . .   . .     . .   . .     . . . . .     .     .  .       . . . .    . . .       .      . . . .    . . .        .    .      .  ▶                   
              
2     2018
              
Total  .    .  . .       . . . . . .   . . .      . . .   . .     . .   . .     . . . . .     .     .  .       . . . .    . . .       .      . . . .    . . .        .    .      .  ▶                   
              
3     2019
              
Total  .    .  . .       . . . . . .   . . .      . . .   . .     . .   . .     . . . . .     .     .  .       . . . . .    . .       .      . . . . .    . .        .    . .       ▶
                                                                                                                                                                                          Form 965-A (Rev. 1-2020)

Form 965-A (Rev. 1-2020)                                                                                                                                                                                      Page 3
Part IV  Annual Report of Deferred Net 965 Tax Liability Related to 965 Amounts Allocated From S Corporations 
         (required every year until the liability is fully paid)
           (a)                                                       (b)                                                                           (c)                   (d) 
         Election or                                     S Corporation Name                                                                    S Corporation             Beginning Deferred 
         Transfer Year                                                                                                                       Tax Identification Number   Net 965 Tax Liability 
                                                                                                                                                                         (see instructions)
1                                                                                                                                                                                                             1
2                                                                                                                                                                                                             2
3                                                                                                                                                                                                             3
4                                                                                                                                                                                                             4
5                                                                                                                                                                                                             5
6                                                                                                                                                                                                             6
7                                                                                                                                                                                                             7
8                                                                                                                                                                                                             8
9                                                                                                                                                                                                             9
10                                                                                                                                                                                                            10
                           (e)                       (f)                                                     (g)                                   (h)                   (i) 
           Reserved for Future Use             Net 965 Tax Liability                                   Deferred 965 Net Tax Liability        Tax Identification Number   Deferred Net Tax Liability  
                                                   Triggered                                             Transferred (Out) or                of Transferee or Transferor at the end of this Reporting Year 
                                                 (see instructions)                                  Transferred In by Agreement, if any                                 (add columns (d), (e), (f), and (g)) 
                                                                                                           (see instructions)                                            (see instructions)
1                                        (                                                       )                                                                                                            1
2                                        (                                                       )                                                                                                            2
3                                        (                                                       )                                                                                                            3
4                                        (                                                       )                                                                                                            4
5                                        (                                                       )                                                                                                            5
6                                        (                                                       )                                                                                                            6
7                                        (                                                       )                                                                                                            7
8                                        (                                                       )                                                                                                            8
9                                        (                                                       )                                                                                                            9
10                                       (                                                       )                                                                                                            10

Total  . . .   .         . .   . . . . . . . . . . . .   .   .       .   . .                       . . . . . . . . .          .       .  . . . . . .   .     .  ▶
If more lines are needed for any Part on this form, attach additional sheets.
                                                                                                                                                                            Form 965-A (Rev. 1-2020)