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