Form 8975 sch A 8975 sch A Tax Jurisdiction and Constituent Entity Information

SCHEDULE A
(Form 8975)

Tax Jurisdiction and Constituent Entity Information
For reporting period beginning

(June 2017)

▶

Department of the Treasury
Internal Revenue Service

, 20

, and ending

, 20

OMB No. 1545-2272

A separate Schedule A (Form 8975) is to be completed for each tax jurisdiction of the multinational enterprise group.
▶ Information about Schedule A (Form 8975) and its separate instructions is at www.irs.gov/form8975.

Name of the reporting entity

Part I

EIN

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

Tax jurisdiction

1. Revenues
(a)
Unrelated party

Part II

(b)
Related party

(c)
Total

2. Profit (loss) before
income tax

3. Income tax paid
(on cash basis)

4. Income tax
accrued—current
year

5. Stated capital

6. Accumulated
earnings

7. Number of
employees

8. Tangible assets
other than cash and
cash equivalents

Constituent Entity Information
1. Constituent entities resident in
the tax jurisdiction

For Paperwork Reduction Act Notice, see separate instructions.

2. TIN

3. Tax jurisdiction of
organization or
incorporation if
different from tax
jurisdiction of
residence

Cat. No. 69310N

4. Main business activities
(a)
Activity code

(b)
If you entered the code for “Other,” describe the
business activity

Schedule A (Form 8975) (6-2017)

Page 2

Schedule A (Form 8975) (6-2017)

Part II

Constituent Entity Information (continued)
1. Constituent entities resident in
the tax jurisdiction

Part III

2. TIN

3. Tax jurisdiction of
organization or
incorporation if
different from tax
jurisdiction of
residence

4. Main business activities
(a)
Activity code

(b)
If you entered the code for “Other,” describe the
business activity

Additional Information

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

Schedule A (Form 8975) (6-2017)