SCHEDULE K                      Shareholder's Statement of IC-DISC Distributions                                                      OMB No. 1545-0123
(Form 1120-IC-DISC)                            For calendar year                20              or tax year
(Rev. December 2016)                                                                                                                 COPY A—Attach to 
                             beginning                                          , 20   , ending                            , 20
Department of the Treasury                                                                                                           Form 1120-IC-DISC
Internal Revenue Service        (Complete for each shareholder. See instructions on back of Copy C.)
Part I   Taxable Distributions
1  Deemed distributions:     a Under section 995(b)(1)  .                            . . . .    .  .   .   . . . .         .   . . . 1a
                             b Annual installment under section 995(b)(2)  .                           .   . . . .         .   . . . 1b
                             c Total. Add lines 1a and 1b .                            . . .    .  .   .   . . . .         .   . . . 1c
2  Actual taxable distributions  .     . . . . . .                              . .  . . . .    .  .   .   . . . .         .   . . . 2
3  Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below .                                 . . 3
Section A—C Corporations
4a Part of line 3 above entitled to section 243 dividends-received deduction .                             . . . .         .   . . . 4a
b  Part of line 3 above not entitled to section 243 dividends-received deduction  .                            . .         .   . . . 4b
Section B—Shareholders Other Than C Corporations
5  Amount of taxable dividends included on line 3  .                              .  . . . .    .  .   .   . . . .         .   . . . 5
Part II  Nontaxable Distributions
6  Actual distributions from previously taxed income and accumulated pre-1985 DISC income                                        . . 6
7  Other actual nontaxable distributions .   . . .                              . .  . . . .    .  .   .   . . . .         .   . . . 7
8  Total nontaxable distributions. Add lines 6 and 7  .                              . . . .    .  .   .   . . . .         .   . . . 8
Part III Other Information
9  Accumulated IC-DISC income attributable to stock sold during the year  .                                . . . .         .   . . . 9
10 Deferred DISC income. See instructions .    . .                              . .  . . . .    .  .   .   . . . .         .   . . . 10
                                                                                         Name, employer identification number, and address (including ZIP code)  
Shareholder’s name, identifying number, and address (including ZIP code)                 of IC-DISC, former DISC, or former IC-DISC

For Paperwork Reduction Act Notice, see the Instructions for Form 1120-IC-DISC. www.irs.gov/form1120icdisc Cat. No. 11474A Schedule K (Form 1120-IC-DISC) (Rev. 12-2016)

SCHEDULE K                      Shareholder's Statement of IC-DISC Distributions                                            OMB No. 1545-0123
(Form 1120-IC-DISC)                            For calendar year                20    or tax year                            COPY B— 
(Rev. December 2016)         beginning             , 20                      , ending                    , 20              For Shareholder's 
Department of the Treasury                                                                                                   records
Internal Revenue Service   
Part I   Taxable Distributions
1  Deemed distributions:     a Under section 995(b)(1)  .                  . . . .    .  .   .   . . . . . .  .          . 1a
                             b Annual installment under section 995(b)(2)  .                 .   . . . . . .  .          . 1b
                             c Total. Add lines 1a and 1b .                  . . .    .  .   .   . . . . . .  .          . 1c
2  Actual taxable distributions  .     . . . . . . .                     . . . . .    .  .   .   . . . . . .  .          . 2
3  Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below .              .          . 3
Section A—C Corporations
4a Part of line 3 above entitled to section 243 dividends-received deduction .                   . . . . . .  .          . 4a
b  Part of line 3 above not entitled to section 243 dividends-received deduction  .                  . . . .  .          . 4b
Section B—Shareholders Other Than C Corporations
5  Amount of taxable dividends included on line 3  .                     . . . . .    .  .   .   . . . . . .  .          . 5
Part II  Nontaxable Distributions
6  Actual distributions from previously taxed income and accumulated pre-1985 DISC income                     .          . 6
7  Other actual nontaxable distributions .   . . . .                     . . . . .    .  .   .   . . . . . .  .          . 7
8  Total nontaxable distributions. Add lines 6 and 7  .                    . . . .    .  .   .   . . . . . .  .          . 8
Part III Other Information
9  Accumulated IC-DISC income attributable to stock sold during the year  .                      . . . . . .  .          . 9
10 Deferred DISC income. See instructions .    . . .                     . . . . .    .  .   .   . . . . . .  .          . 10
                                                                               Name, employer identification number, and address (including ZIP code)  
Shareholder’s name, identifying number, and address (including ZIP code)       of IC-DISC, former DISC, or former IC-DISC

www.irs.gov/form1120icdisc                   Cat. No. 11474A                                         Schedule K (Form 1120-IC-DISC) (Rev. 12-2016)

Instructions for Shareholder                      Line 5. If you are an individual, partnership,    received a distribution with respect to that 
                                                  S corporation, estate, or trust, line 5 shows     stock, you may be able to treat part of that 
Section references are to the Internal Revenue    the amount of line 3 distributions taxable to     distribution as a nontaxable distribution. See 
Code.                                             you as a dividend.                                section 996(d) for details.
Purpose of forms. Copy B of Schedule K            For a tax-exempt entity, treat any deemed         Part II—Nontaxable Distributions
(Form 1120-IC-DISC) reports an actual or          distribution or actual distribution of previously 
deemed distribution from an IC-DISC, former       untaxed income as derived from the conduct        Actual distributions from previously taxed 
IC-DISC, or former DISC. It also reports          of an unrelated trade or business.                income and accumulated pre-1985 DISC 
deferred DISC income from an IC-DISC.                                          If you disposed      income are generally not taxable to the extent 
Keep it for your records; do not file it with     Disposing of IC-DISC stock.                       of your basis in the stock for which the 
your income tax return.                           of stock in an IC-DISC, former IC-DISC, or        distribution was made. Except for 
                                                  former DISC, you may need to include all or 
Part I—Taxable Distributions                      part of the gain in your income. The gain,        distributions of accumulated IC-DISC income 
                                                  reported as a dividend under section 995(c), is   and of earnings and profits from the time 
Report as distributions from an IC-DISC:          included to the extent of accumulated             before the corporation became an IC-DISC, 
1. Deemed and actual taxable distributions;       IC-DISC income attributable to the stock          actual distributions are not taxable to the 
and                                               while you held it (line 9). This dividend is not  extent of your basis in the stock for which the 
2. Gain, to the extent of accumulated             eligible for the section 243 deduction.           distribution was made. Treat distributions in 
                                                                                                    excess of your basis as a gain from the sale 
IC-DISC income, on the sale of stock (see         For a tax-exempt entity, treat the gain           or exchange of property. See section 996(e).
Disposing of IC-DISC Stock below).                under section 995(c) as derived from the 
Line 1—Deemed distributions. You are              conduct of an unrelated trade or business.        Part III—Other Information
treated as having received deemed                 Foreign shareholders treat all gains on the       Line 10—Deferred DISC income. Line 10 
distributions (line 1c) as of the last day of the disposition of stock in an IC-DISC, former        shows your share of the IC-DISC’s deferred 
IC-DISC tax year. You must pay tax on the         IC-DISC, or former DISC, and all distributions    income for the year. Section 995(f) imposes 
distributions in your tax year that includes that from accumulated IC-DISC income or                an interest charge on the additional tax you 
date.                                             accumulated pre-1985 DISC income,                 would pay if you included this deferred 
Line 2—Actual taxable distributions. You          including deemed distributions, as effectively    income in your income for your tax year that 
must pay tax on actual taxable distributions in   connected with the conduct of a trade or          ends with or includes the IC-DISC’s tax year 
the year of receipt.                              business through a permanent establishment        end shown on Schedule K. Complete Form 
                                                  within the United States. See section 996(g)      8404, Interest Charge on DISC-Related 
Line 4. Line 4a shows the part of the total       for details.                                      Deferred Tax Liability, to figure the interest 
taxable distribution on line 3 that qualifies for                                                   charge.
the 70% or 80% dividends-received                 Acquiring IC-DISC stock. If you acquired 
deduction under section 243. Line 4b shows        stock in an IC-DISC and subsequently              Future developments. For the latest 
the part that does not qualify for the                                                              information about developments related to 
deduction.                                                                                          Schedule K (Form 1120-IC-DISC) and its 
                                                                                                    instructions, such as legislation enacted after 
                                                                                                    they were published, go to www.irs.gov/
                                                                                                    form1120icdisc.

                                                                                                    Schedule K (Form 1120-IC-DISC) (Rev. 12-2016)

SCHEDULE K                      Shareholder's Statement of IC-DISC Distributions                                            OMB No. 1545-0123
(Form 1120-IC-DISC)                            For calendar year                20    or tax year
(Rev. December 2016)                                                                                                         COPY C— 
                             beginning             , 20                      , ending                    , 20
Department of the Treasury                                                                                                 For IC-DISC's records
Internal Revenue Service        (Complete for each shareholder. See instructions on back of Copy C.)
Part I   Taxable Distributions
1  Deemed distributions:     a Under section 995(b)(1)  .                  . . . .    .  .   .   . . . . .   . .         . 1a
                             b Annual installment under section 995(b)(2)  .                 .   . . . . .   . .         . 1b
                             c Total. Add lines 1a and 1b .                  . . .    .  .   .   . . . . .   . .         . 1c
2  Actual taxable distributions  .     . . . . . . .                     . . . . .    .  .   .   . . . . .   . .         . 2
3  Total taxable distributions. Add line 1c and line 2. Enter here and in Section A or B below .               .         . 3
Section A—C Corporations
4a Part of line 3 above entitled to section 243 dividends-received deduction .                   . . . . .   . .         . 4a
b  Part of line 3 above not entitled to section 243 dividends-received deduction  .                  . . .   . .         . 4b
Section B—Shareholders Other Than C Corporations
5  Amount of taxable dividends included on line 3  .                     . . . . .    .  .   .   . . . . .   . .         . 5
Part II  Nontaxable Distributions
6  Actual distributions from previously taxed income and accumulated pre-1985 DISC income                      .         . 6
7  Other actual nontaxable distributions .   . . . .                     . . . . .    .  .   .   . . . . .   . .         . 7
8  Total nontaxable distributions. Add lines 6 and 7  .                    . . . .    .  .   .   . . . . .   . .         . 8
Part III Other Information
9  Accumulated IC-DISC income attributable to stock sold during the year  .                      . . . . .   . .         . 9
10 Deferred DISC income. See instructions .    . . .                     . . . . .    .  .   .   . . . . .   . .         . 10
                                                                               Name, employer identification number, and address (including ZIP code)  
Shareholder’s name, identifying number, and address (including ZIP code)       of IC-DISC, former DISC, or former IC-DISC

www.irs.gov/form1120icdisc                   Cat. No. 11474A                                         Schedule K (Form 1120-IC-DISC) (Rev. 12-2016)

Instructions for IC-DISC                        Line 2. Enter the amount of actual              (3) other earnings and profits. The total of this 
                                                distributions that are taxable to the           line for all shareholders should equal the total 
Section references are to the Internal Revenue  shareholder. These distributions come from      nontaxable income reported on                 
Code.                                           accumulated IC-DISC income and other            Form 1120-IC-DISC, Schedule J, Part IV, line 
Future developments. For the latest             earnings and profits.                           4d.
information about developments related to       Line 4a. Enter on line 4a each shareholder’s    Part III—Other Information
Schedule K (Form 1120-IC-DISC) and its          amount of dividends out of other earnings and 
instructions, such as legislation enacted after profits that are eligible for the dividends-    Line 9. If (1) a shareholder disposes of stock 
they were published, go to www.irs.gov/         received deduction under section 243. No        in an IC-DISC or former DISC, or (2) the stock 
form1120icdisc.                                 dividends-received deduction is allowed for a   of an IC-DISC, former IC-DISC, or former 
                                                dividend from an IC-DISC, former IC-DISC, or    DISC is disposed of in a transaction that 
General Instructions                            former DISC if it is:                           terminates the separate corporate existence 
Complete Schedule K (Form 1120-IC-DISC)         1. Paid out of accumulated IC-DISC income       of an IC-DISC, former IC-DISC, or former 
for each shareholder who had an actual or       or accumulated pre-1985 DISC income,            DISC (other than a mere change in the place 
                                                                                                of organization), enter on line 9 the 
deemed distribution during the tax year or to   2. Paid out of previously taxed income, or      accumulated IC-DISC income attributable to 
whom the corporation is reporting deferred 
DISC income for the tax year. Attach Copy A     3. A deemed distribution under section          the stock that was accumulated during the 
to Form 1120-IC-DISC. Give Copy B to the        995(b)(1).                                      period the shareholder held the stock.
shareholder by the last day of the second       Line 5. Complete for shareholders that are      Line 10. Enter the shareholder’s share of the 
month after your tax year ends. Keep Copy C     individuals, partnerships, S corporations,      corporation’s deferred DISC income at tax 
for your records.                               estates, or trusts. Enter on line 5 each        year end. See section 995(f) and the 
Note: Do not report on Form 1099-DIV actual     shareholder’s pro rata share of taxable         instructions for Schedule J, Part V, in the 
and deemed distributions or deferred DISC       dividends included on line 3.                   Instructions for Form 1120-IC-DISC for 
income.                                                                                         information on figuring deferred DISC income. 
                                                Part II—Nontaxable Distributions                The total of this line for all shareholders 
Specific Instructions                           Line 6. Enter the shareholder’s pro rata share  should equal the total amount reported on 
                                                of actual distributions from previously taxed   Form 1120-IC-DISC, Schedule J, Part V,     
Part I—Taxable Distributions                    income and distributions from accumulated       line 3.
Line 1. On line 1a, enter the shareholder’s pro pre-1985 DISC income. The total of line 6 for 
rata share of the deemed distributions under    all shareholders should equal the total the 
section 995(b)(1). On line 1b, enter the        corporation reports on Form 1120-IC-DISC, 
shareholder’s pro rata share of the annual      Schedule J, Part IV, line 4a.
installment under section 995(b)(2). The sum    Line 7. Enter the shareholder’s pro rata share 
of the amounts on these lines for all           of actual nontaxable distributions out of other 
shareholders should equal the total the         than (1) previously taxed income or 
corporation reports in Part I and Part III,     accumulated pre-1985 DISC income,           
Schedule J, Form 1120-IC-DISC.                  (2) accumulated IC-DISC income, and

                                                                                                Schedule K (Form 1120-IC-DISC) (Rev. 12-2016)