1017 Form 8883 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8883.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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

City or town, state, and ZIP code

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. ^▶

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

Form 8883 (Rev. 10-2017)