Form 1125-E Compensation of Officers

Form

1125-E

Compensation of Officers

(December 2011)

▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-XXXX

Attach to Form 1120, 1120-C, 1120-F, 1120-RIC.
▶ See separate instructions.

Employer identification number

Name

f
o
s
a
1
t
1
f
0
a
2
r
/
D /05
7
0

Note. Complete Form 1125-E only if total receipts are $500,000 or more. See instructions for definition of total receipts.
(a) Name of officer

1

(c) Percent of
time devoted to
business

(b) Social security number

Percent of stock owned

(d) Common

(e) Preferred

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Total compensation of officers .

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Compensation of officers claimed on Form 1125-A or elsewhere on return

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Subtract line 3 from line 2. Enter the result here and on Form 1120, page 1, line 12 or the
appropriate line of your tax return . . . . . . . . . . . . . . . . . . . . . .

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For Paperwork Reduction Act Notice, see separate instructions.

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Cat. No. 55989C

(f) Amount of
compensation

Form 1125-E (12-2011)