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pdf8937
Report of Organizational Actions
Affecting Basis of Securities
Form
(December 2017)
Department of the Treasury
Internal Revenue Service
Part I
▶ See
separate instructions.
Reporting Issuer
1 Issuer's name
2 Issuer's employer identification number (EIN)
3 Name of contact for additional information
4 Telephone No. of contact
6 Number and street (or P.O. box if mail is not delivered to street address) of contact
8 Date of action
10 CUSIP number
Part II
OMB No. 1545-0123
5 Email address of contact
7 City, town, or post office, state, and ZIP code of contact
9 Classification and description
11 Serial number(s)
12 Ticker symbol
13 Account number(s)
Organizational Action Attach additional statements if needed. See back of form for additional questions.
14
Describe the organizational action and, if applicable, the date of the action or the date against which shareholders' ownership is measured for
the action ▶
15
Describe the quantitative effect of the organizational action on the basis of the security in the hands of a U.S. taxpayer as an adjustment per
share or as a percentage of old basis ▶
16
Describe the calculation of the change in basis and the data that supports the calculation, such as the market values of securities and the
valuation dates ▶
For Paperwork Reduction Act Notice, see the separate Instructions.
Cat. No. 37752P
Form 8937 (12-2017)
Page 2
Form 8937 (12-2017)
Part II
Organizational Action (continued)
17
List the applicable Internal Revenue Code section(s) and subsection(s) upon which the tax treatment is based ▶
18
Can any resulting loss be recognized? ▶
19
Provide any other information necessary to implement the adjustment, such as the reportable tax year ▶
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
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Date ▶
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Print your name ▶
Print/Type preparer's name
Paid
Preparer
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Preparer's signature
Title ▶
Date
Check
if
self-employed
Firm's name
▶
Firm's EIN
Firm's address
▶
Phone no.
PTIN
▶
Send Form 8937 (including accompanying statements) to: Department of the Treasury, Internal Revenue Service, Ogden, UT 84201-0054
File Type | application/pdf |
File Title | Form 8937 (Rev. December 2017) |
Subject | Fillable |
Author | SE:W:CAR:MP |
File Modified | 2017-11-30 |
File Created | 2017-11-30 |