Affiliations Schedule

• Legal Form Number: 851
• Year: 2016
• Issuer: Treasury Department
• Section: Treasury Department

Form 851

(Rev. October 2016)

Department of the Treasury

Internal Revenue Service

Affiliations Schedule

For tax year ending ,

▶ File with each consolidated income tax return.

▶ Information about Form 851 and its instructions is at www.irs.gov/form851.

OMB No. 1545-0123

Name of common parent corporation Employer identification number

Number, street, and room or suite no. If a P.O. box, see instructions.

City or town, state, and ZIP code

Part I Overpayment Credits, Estimated Tax Payments, and Tax Deposits (see instructions)

Corp.

No. Name and address of corporation

Employer

identification

number

Portion of

overpayment credits

and estimated

tax payments

Portion of tax

deposited with

Form 7004

1 Common parent corporation

2

Subsidiary corporations:

3

4

5

6

7

8

9

10

Totals (Must equal amounts shown on the consolidated tax return.) . . . . ▶

Part II Principal Business Activity, Voting Stock Information, Etc. (see instructions)

Corp.

No. Principal business activity (PBA)

PBA

Code

No.

Did the subsidiary

make any nondividend

distributions?

Stock holdings at beginning of year

Number

of

shares

Percentage

of voting

power

Percentage

of value

Owned by

corporation

no.

Yes No

1

Common parent corporation

2

Subsidiary corporations:

% %

3 % %

4 % %

5 % %

6 % %

7 % %

8 % %

9 % %

10 % %

For Paperwork Reduction Act Notice, see instructions. Cat. No. 16880G Form 851 (Rev. 10-2016)