Form 1120-IC-DISC (Sch. 1120-IC-DISC (Sch. Shareholder's Statement of IC- DISC Distributions

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Page 1 of 6 of Schedule K (Form 1120-IC-DISC)
(Page 2 is blank) (3-Part) (2 up)

1

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

SCHEDULE K
(Form 1120-IC-DISC)
Department of the Treasury
Internal Revenue Service

1

2
3

Date

Signature

O.K. to print
Revised proofs
requested

Date

Part I

Action

Shareholder’s Statement of IC-DISC Distributions—2009
For calendar year 2009 or tax year

beginning

, 20

Deemed distributions: a Under section 995(b)(1)
b Annual installment under section 995(b)(2)
c Total. Add lines 1a and 1b
Actual taxable distributions
Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below

Section A—C Corporations

COPY A—Attach to
Form 1120-IC-DISC

f
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s
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0
f
0
a
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D /05
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0
, 2009, ending

(Complete for each shareholder. See instructions on back of Copy C.)

Taxable Distributions

OMB No. 1545-0938

1a
1b
1c
2
3
4a
4b

4a Part of line 3 above entitled to section 243 dividends-received deduction
b Part of line 3 above not entitled to section 243 dividends-received deduction

Section B—Shareholders Other Than C Corporations
5

Amount of taxable dividends included on line 3

Part II
6
7
8

5

Actual distributions from previously taxed income and accumulated pre-1985 DISC income
Other actual nontaxable distributions
Total nontaxable distributions. Add lines 6 and 7

Part III
9
10

Nontaxable Distributions

Other Information

Accumulated IC-DISC income attributable to stock sold during the year
Deferred DISC income. See instructions

Shareholder’s name, identifying number, and address (including ZIP code)

For Paperwork Reduction Act Notice, see the instructions for Form 1120-IC-DISC.

6
7
8

9
10

Name, employer identification number, and address (including ZIP code)
of IC-DISC, former DISC, or former IC-DISC

Cat. No. 11474A

Schedule K (Form 1120-IC-DISC) 2009

1

Page 3 of Schedule K (Form 1120-IC-DISC) (3-Part) (2 up)

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

SCHEDULE K
(Form 1120-IC-DISC)
Department of the Treasury
Internal Revenue Service

Part I
1

2
3

Shareholder’s Statement of IC-DISC Distributions—2009
For calendar year 2009 or tax year

beginning

Taxable Distributions

COPY B—
For Shareholder’s
records

f
o
s
a
9
t
0
f
0
a
2
r
/
D /05
8
0
, 2009, ending

, 20

Deemed distributions: a Under section 995(b)(1)
b Annual installment under section 995(b)(2)
c Total. Add lines 1a and 1b
Actual taxable distributions
Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below

Section A—C Corporations

OMB No. 1545-0938

1a
1b
1c
2
3
4a
4b

4a Part of line 3 above entitled to section 243 dividends-received deduction
b Part of line 3 above not entitled to section 243 dividends-received deduction

Section B—Shareholders Other Than C Corporations
5

Amount of taxable dividends included on line 3

Part II
6
7
8

5

Actual distributions from previously taxed income and accumulated pre-1985 DISC income
Other actual nontaxable distributions
Total nontaxable distributions. Add lines 6 and 7

Part III
9
10

Nontaxable Distributions

Other Information

Accumulated IC-DISC income attributable to stock sold during the year
Deferred DISC income. You must complete Form 8404—see instructions

Shareholder’s name, identifying number, and address (including ZIP code)

6
7
8

9
10

Name, employer identification number, and address (including ZIP code)
of IC-DISC, former DISC, or former IC-DISC

Cat. No. 11474A

Schedule K (Form 1120-IC-DISC) 2009

Page 5 of Schedule K (Form 1120-IC-DISC) (3-Part) (2 up)

1

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

SCHEDULE K
(Form 1120-IC-DISC)
Department of the Treasury
Internal Revenue Service

Part I
1

2
3

Shareholder’s Statement of IC-DISC Distributions—2009
For calendar year 2009 or tax year

beginning

, 20

Deemed distributions: a Under section 995(b)(1)
b Annual installment under section 995(b)(2)
c Total. Add lines 1a and 1b
Actual taxable distributions
Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below

Section A—C Corporations

COPY C—
For IC-DISC’s records

f
o
s
a
9
t
0
f
0
a
2
r
/
D /05
8
0
, 2009, ending

(Complete for each shareholder. See instructions on back of Copy C.)

Taxable Distributions

OMB No. 1545-0938

1a
1b
1c
2
3
4a
4b

4a Part of line 3 above entitled to section 243 dividends-received deduction
b Part of line 3 above not entitled to section 243 dividends-received deduction

Section B—Shareholders Other Than C Corporations
5

Amount of taxable dividends included on line 3

Part II
6
7
8

5

Actual distributions from previously taxed income and accumulated pre-1985 DISC income
Other actual nontaxable distributions
Total nontaxable distributions. Add lines 6 and 7

Part III
9
10

Nontaxable Distributions

Other Information

Accumulated IC-DISC income attributable to stock sold during the year
Deferred DISC income. See instructions

Shareholder’s name, identifying number, and address (including ZIP code)

6
7
8

9
10

Name, employer identification number, and address (including ZIP code)
of IC-DISC, former DISC, or former IC-DISC

Cat. No. 11474A

Schedule K (Form 1120-IC-DISC) 2009