Asset Allocation Statement 
Form  8883                                              Under Section 338                                           OMB No. 1545-0123
(Rev. October 2017)
                                               ▶
Department of the Treasury                       Attach to your income tax return. 
Internal Revenue Service    ▶ Go to www.irs.gov/Form8883 for instructions and the latest information.
Part I   Filer’s Identifying Information
1a   Name as shown on return                                                             1b   Identifying number as shown on return

1c    Check applicable box (see instructions):            1d   Was a valid and timely Form 8023 filed? .     . .  .    Yes       No
         Old target         New target                         If "Yes," enter the date filed ▶
Part II  Other Party’s Identifying Information
2a   Name of other party to the transaction                                              2b   Other party’s identifying number

      Address (number, street, and room or suite no.)

      City or town, state, and ZIP code

Part III Target Corporation’s Identifying Information
3a   Name and address of target corporation                                 3b   Employer identification number

                                                                            3c   State or country of incorporation

Part IV  General Information
4a   Acquisition date                                                       4b   What percentage of target corporation stock was 
                                                                              purchased:
                                                                              (i)  During the 12-month acquisition period?         %
                                                                              (ii) On the acquisition date?  . .  . .  .           %
5a   Stock price             5b   Acquisition costs/Selling costs           5c   Target liabilities         5d   AGUB/ADSP

$                            $                                              $                               $
                                                                                                                            Yes No
6     Was the filer listed in Part I, above, a member of an affiliated group of corporations before the acquisition date?  .
7     Was the target corporation a member of an affiliated group before the acquisition date?  .      . . .  . .  . .  .
8     Is the target corporation or any target affiliate:
a     A controlled foreign corporation? If “No,” check here if it was a CFC at any time during the preceding 5 years ▶
b     A foreign  corporation with income, gain, or loss effectively  connected with  the  conduct of  a  trade  or business
      within the United States (including U.S. real property interests)?  . . .    . . . .    .     . . . .  . .  . .  .
c     A qualifying foreign target under Regulations section 1.338-2(e)(1)(iii)?  . . . . .    .     . . . .  . .  . .  .
d     A corporation electing under section 1504(d) or section 953(d)?  .    . .    . . . .    .     . . . .  . .  . .  .
e     A domestic international sales corporation (DISC)?  .    . . . .      . .    . . . .    .     . . . .  . .  . .  .
f     A passive foreign investment company (PFIC)?      . .    . . . .      . .    . . . .    .     . . . .  . .  . .  .
g     If the answer to item 8f is “Yes,” is the PFIC a pedigreed qualified electing fund?  .  .     . . . .  . .  . .  .
For Paperwork Reduction Act Notice, see separate instructions.                     Cat. No. 33707Y                Form 8883 (Rev. 10-2017)

Form 8883 (Rev. 10-2017)                                                                                                       Page 2 
Part V    Original Statement of Assets Transferred
9     Assets               Aggregate fair market value (actual amount for Class I)                   Allocation of AGUB or ADSP

Class I                  $                                                         $

Class II                 $                                                         $

Class III                $                                                         $

Class IV                 $                                                         $

Class V                  $                                                         $

Class VI and VII         $                                                         $

Total                    $                                                         $
Part VI   Supplemental Statement of Assets Transferred—                     Complete if amending an original statement or previously filed 
          supplemental statement because of an increase or decrease in AGUB or ADSP.
10    Enter  the  tax  year  and  tax  return  form  number  with  which  the  original  Form  8023  or  Form  8883  and  any  supplemental 
      statements were filed. ▶
11    Assets               Allocation of sales price as previously reported   Increase or (decrease) Redetermined allocation of AGUB or ADSP

Class I                  $                                                  $                        $

Class II                 $                                                  $                        $

Class III                $                                                  $                        $

Class IV                 $                                                  $                        $

Class V                  $                                                  $                        $

Class VI and VII         $                                                  $                        $

Total                    $                                                                           $
12    Reason(s) for increase or decrease. Attach additional sheets if more space is needed.

                                                                                                             Form 8883 (Rev. 10-2017)