Form 8975 Country-by-Country Report

Form 8975 (December 2016) Department of the Treasury Internal Revenue Service		Country-by-Country Report For reporting period beginning _ _, 20 , and ending , 20__ Information about Form 8975 and its separate instructions at www.irs.gov/form8975						OMB No. XXXX-XXXX
Check if report is being corrected, amended or voided
Corrected report _____			Amended report ____		Voided report ____
PART I	Identification of Filer
1. Name of the multinational entity group							1b. TBD
2. Number, street, and room or suite (If P.O. Box, see instructions)
3a. City or town				3b. State/Province/Region			3c. Country, and ZIP or foreign postal code
4. EIN

PART II

1. Tax jurisdiction

2. Revenues

3.Profit (loss) before income tax

4.Income tax Paid (on cash basis)

5.Income tax accrued – current year

6.Stated capital

7.Accumulated earnings

8.Number of employees

9.Tangible Assets other than cash and cash equivalents

(a)Unrelated party

(b)Related party

(c)Total

A

B

C

PART III

1. Tax jurisdiction

2.Constituent entities resident in the tax jurisdiction

3.TIN

4. Tax Jurisdiction of Organization or Incorporation if Different from Tax Jurisdiction of Residence

5. Main Business Activities

1. Enter Code

2. If you entered the code for “Other”, please describe your Main Business Activity

A

1

2

3

B

1

2

3

PART IV

Additional Information

Enter any additional information that clarifies the information reported in Part II and III.