Form 5471 Form 5471 Information Return of U.S. Persons With Respect To Certa

Farm

Informatjon Return of U.S. Persons With
Respect To Certain Forelgn Corporations

5471
2607

(Rev. December a896)

b See separate instrucrrons.

D*yarlmtnl o l me Treasury
hr+mal Rwsmrd Ss~lco

Information fum~shedfor the foreign corporation's annual accounting p e r i d (tax year requlred by
section 898) (see rnstructionsl beginning
, 20
, and end~ng
. 20

Wher
nslruclans

Name at p e r m l h g Ihs relurn
I

r*mtrer. st,-.

3M mom

or su~tenc

C ~ t yor town, state, and ZIP code

~ ( O TP

I

U mn nmmr 11m a hv nc4 delivered to strmgt address! B

-..---- -

Category ot filer (See ~nslructlm.
Check applicable boqes)).

1 (repealea 2

you mned at the end of ~ t sannual accounting pwrod

F~ler'starr year beg~nnlng
D

,20

Porsm[s) on whcss Wl thrs infwrmalm return

IS

5 - 0

4

3

C Enter t b lot& perc?ntage 01 the foreign corporatlon's votrng stock

--

. and enolng

. . ... .

...

. -96

,20

flled.
(4) Check applicaMe b x w )

(3) I d e n t l t p g nVmbw

(1) Name

Stwfkhlal Offlcer

I

I

I

1

I

Dmfor

I

Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be stated
in U.S. doliars unless otherwise indicated.
b Employer ~dent~fieal~on
mmber, 11any

l a Name and aQQrtW3 of rwe~gncormfat~m

1
d Date of mcofpz#atJon

R I ~ Kplace
? A of
~ busims

v

I Principal buslnffs acllurty

c County under whore laws iocorporatod

I

Pr~ncloalbuslness actrvlty

h Fmmimal rurtenq

code number

2

P

w the f d l o w ~ ~
~nImm&on
g
tor the l o r @ i g n m W saccouming perlod stated above.

a Nam h
s and ldent~fylragnumber of branch d
t b U n l w Stales

w or went [ ~ any)
f
m

b H a U 5. income lax renm was bled. enter:

p) Taxable mcwne or floss)

c Name and address 01 iweqn corporation's shtutory ar res~dsmagem

uxlntry of l n c m t l o n

UI

W

U.S. Income la* palo
(&or al! credlrs)

d Name and address (including crvporate aeparhnsnt. ~fapplicable) of
person (wp r s m s ) with custody of the k o k s and rem& of the foreign
corporation. and the locat~onof aueh w o k s and records. if different

(b] Number of shares issued and mtandlng

(a) OawrlFkon d eacn class of s l m k
accuuntlng mrmd

For Papemwk Reduction Act Notice. see instructions.

Cat No. 4995BV

(If) End al annua
account~ngper~Dd

Fwm

5471

LRw. 12?0#5)

do07

DRAFT

2J4 7

Form 5471 W .12.-

U.S. Shareholders of Foreign Corporation (see ~nstructians)
(c) m
r of
*"he(d a'
beginning 01

(bl Dcscr~fl~on
of each class ol stack

hdrl by
shareholder Noie: The; descr~plrmrshould m l c h the

(a) Name, address, and identifying
number of shareholder

c w r t s * c n a n g descnplrorr entered fn S c t e M e A.

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OF-"--I@)
IhWe

(dl N-I

shw6

5''hpart

Cna 01 m u *

anwl
accounting panod

columrr (a-

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---

lncarne (snkr as
a perwnlage)

*t-ntrng

m~oa

I

I

Income Statement (see instructions
-ePort
ail information in functional cumm!zy in accordancs with U.S. GAAP Also, report each amount in
U.S. do//ars Iranslaled from functional currency {using GAAP translation rules]. Hawever, if the functional c u r m y is
the U.S. dollar, complete only the U.S. Dollars column. See instructions for special rules far DASTM corporations.

I

[

-g

ta
b
c
2

3
4

5
6
7
8

10
11
12

13

$

14

3 15
16

77

Gross receipts or sales . . . .
.
Returns and allowances. . . . . . .
Subtract line l b from line l a . . . .
Cost af goods sold
. . . . . . . .
Gmss prof) [sublracl line 2 from line Ic) .
Dividends. . . . . . . . . . . .
Interest. . . . . . . . . . . . .
Gross rents. royalties, and I~censefees . .
Net gain w W s ) on sale of capital assets .
Other income (attach schedule) . . . .

.
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.

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[

la

I

. . . . . . . . .
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. . . . . . . . . . 6
. . . . . . . . . . 7

. . . . . . . . . . . . 8
. . . . . . . . . . . . . .
9

Campensation not deducted elsewhere.
Rents, royalties, and license fees . . .

. . . . . . . . . . . .

10

. . . . . . . . . . . .
Interest. . . . . . . . . . . . . . . . . . . . . . .
Depreciation not deducted elsewhere
. . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . . . . . .
Taxes (exclude provision for income, war protlts, and excess profils taxes) .
Other deductions (attach s e h e d u l ~ r c l u d eprovision for income, war profits,
and excess profits taxes). . . . . . . . . . . . . . . . . . .
Total deductions (add lines 1O through 1 6 ) . . . . . . . . . . . .

2 I $8 Net income or (loss) before extraordinary items, prior pefiod adjustments. and

1

$6
17

I

I

I

I

the probrslon for ncome, war profits. and excess potlts taxes (subtract line

. . . . . . . . . .

Form

5471 (ReJ

12-m)

J.c

137

Page

Form 5471 (Rov. 12

IL .---...-..-.."."..--

I

la)
Name of coontry or U S oassessldn

I

-

1

I

el
in f a a g n smency

Amount
of tax
i.,

Cawers~onrate

I

r

..

I

3

+-

i?olhrs

-

U.S.

-.

. . . . .
. . . . . . . . . . . . .
. .
Balance Sheet
Important: Report all amounts in U.S. dollars prepared and translaw in accordance with U.S. GAAP. See instructions
for an exception for DASTM corpomtions.
8

Total.

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. . . . . . . .

1 Cash. . . . . . . . . . . . . . . . .
20 Trade notes and amounts rece~vable . . . . . .
b Less allowance for bad debts . . . . . . . .
3 Inventories . . . .
. . . . . . . .
4 Othercurrentassets(attach schedule] . . . . .
5 Loans to shareholders and other related persons . .
8 Investment in subsrd~aries(attach schedule) . . . .
7 Other investments (attach sckdule) . . . . . .
8a Buildings and other depreciable assets . . . . .
b Less accumulated depreciation . . . . .
. .
9a Depletable assets . . . . . . . . .
. .
b Less accumulated deplelion . . . . . . . . .
10 Land (net of any amortization) . . . . . . .
11 In tangible assets:
a Goodwill. . . . . . . . . . . . . . . .
b Organization costs . . . . . . . . . . . .
c Patents, trademarks, and other intangible assets . .
d Less accumulated amortization tor lines Ila, b, and c
12 Other
(attach schedule) . . . . . . . .
13

Total assets

bl

(0)

Assets

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1

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1

1(

1

6
7

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1(

5

8a
8b (
9a
gb (

10

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1

4

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1

3

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aCCOUfl~
mod

2b .(

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.
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.

~ n d
d mnd

accounting period

1
2a

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w i n g or annua

lfa
ttb
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l*d (

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12

. . . . . . . . . . . . . . . . . . . . . .
Liabilities and Shareholders' Equity

13

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=

%.,

.
. . .. . .

Accounts payable. .
. .
. . . . .
Other current liabrlit~es(attach schedule)
Loans from shareholders and other related persons
Other liabilit~es(atlachschedule)
Capital stock:
Preferred stock . . . . . . . . . .
Common stock . . . . . . . . . . .
Paid-n or capital surplus (altach reconciliation).
Retamed earnlngs . . . . . . . . . .
Less cast of treasuv slock . . . . . . .

. . .

. . . . .

22

Total liabilit~esand shareholders' equity

. . . . . . . . . . .

1

22

1
Form

5471

(Rev. 1 2 - m i

J-el?'1

DRAFT

1,
J

/

. . . . . . . .
Dunne the tax ~ n rwas
, the foreign colporation a parllclpanl in a cos1 sha!li>p arrangement''
D u r ~ l ~the
p tar year,did rhe fore~gncorporation k c o m a panlclranl r l ) a rosr shar~nzarranpcment9 , . , C

4
5

0

.

T:

>

2067

F v l m Y I 1 (Rev

Page

12-1804

--

Other Information

I

4

Yes No

I

1

i.

2
3

I

;
I
,

During the tax year, did the foreign corporation o w n a, least a 10% interest, directly or indirectly, in any foreign
partnership? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
flcl
If "Yes," see the ~nstructionslor required attachment.
During the tax year, did the foreign corporation own an interest in any trust?. . . , . . . . . , . . .
During the tax year, did the lar.gn corporation own any foreign entities that were disregarded as entities separate
from their owners under Regulations sections 301.7701-2 and 301.770 1 -3 (see instructions)? . . . . . . .
(7
If "Yes," you are generally required to attach Form 8858 for each entity (see instructions).

n

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\

\..--+."

Current Earnings and Profits (see instructions)
Important: Enter the amounts on lines I through 5c in functional currency.
1 Current year net income or [loss) per foreign books of account . . . . . . .
2

Net adjustments made to Ine t to determine current
earnings and profits according to U.S.financial and tax
accounting standards (see instructions):

Additions

. . . .

1

]

Subtractions

a Capital gains or losses
. . . . .
b Depreciation and amortization . . . . . . . .
c Depletion . . . . . . . . . . . . . . .
d Investment or incentive allowance . . . . . . .
e Charges lo statutory reserves. . . . . . . . .
1 Inventory adjustments . . . . . . .
. . .
g Taxes. . . . . . . . . . . . . . . . .
h Other (attach schedule) . . . . . . . . . .
'.
3 Total net additions . . .
. . . . . . .
4 Total net subtractions . . . . . . . . . . . . . . . . . .
5a Current eamngs and profits (line 1 plus line 3 minus line 4) , , , ,
. . . . .
b DASTM gain or {loss] for foreign corporations that use DASTM (see rnstruetions) . . .
c Combine lines 5a and 5b . . . . . . . . . . . . . . . . . . . . . . .
d Current earnings and profits in U.S.dollars (line 5c translated at the appmprlate exchange
defined in section 989(b) and the dated regulations {see instructions)) . . . . . . .
Enter exchange rats used for line 5d b
I
Summary of Shareholder's Income From Foreign Corp
m

.

"

. . .
. . .
. .
rate as
. . .

1

Subpart F income (line 38b. Worksheet A in the instructions) .

2

Earnings invested in U.S. property (line 17. Worksheet B in the instructions) . . . . . . . .
Previously excluded subpart F income withdrawn lrom qualified investments (line 6b, Worksheet C
in the instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
Previously excluded ex@ trade Income wrthdrawn from investment in export trade assets (line 7b.
Worksheet D in the instructions). . . . .
. . . . . . . . . . . . . . .

3
4

5a
6b

5c
5d

. . . . .

i

. . . - .. .

. . .

5

Factwing income

6

Total of lines 1 through 5. Enfer here and on

7

Drvidends received {traitslated at spot rate on payment date under section 989(b)tl)) . . . .
..
Excharlge
or*(lo&) on a distribution of previousty taxed income ,
. . . . . . .

8

your income tax return. See instructions.

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.

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7

[I

8
Yes No

Was any income of the foreign corporation blocked?.
. . . . . . . . . . . . . . . .
. . .
Did any such income become unblocked during the tax year (see secbon 964(b))?. . . . . . . . . . . .
If the answer to ether question is "Yes,'' attach an explanal~on.
Form

DRAFT

5471

.a
17
rRev 12.-

[3