8975 Country-by-Country Report

Form

8975

Country-by-Country Report
For reporting period beginning

(June 2017)
Department of the Treasury
Internal Revenue Service

, 20

, and ending

OMB No. 1545-2272

, 20

▶ Information about Form 8975 and its separate instructions is at www.irs.gov/form8975.

If this is an amended report, check here
Enter the number of Schedules A (Form 8975) attached to this Form 8975 ▶

Part I

Identification of Filer

1a Name of the reporting entity
2

1b Reporting role code

1c EIN

Number, street, and room or suite no. (if P.O. box, see instructions)

3a City or town

Part II

3b State or province

3c Country, and ZIP or foreign postal code

Additional Information

Enter any additional information related to the multinational enterprise group.

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 37798N

Form 8975 (6-2017)

Form 8975 (6-2017)

Part II

Page 2

Additional Information (continued)

Form 8975 (6-2017)