Information Return of U.S. Persons with Respect To Certain Foreign Corporations

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE M (FORM 5471), PAGE 1 of 2 (PAGE 2 IS BLANK)
PRINTS: FACE ONLY
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PAPER: WHITE WRITING, SUB. 20.
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279mm (11")
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Date

Action

Date

O.K. to print
Revised proofs
requested

Transactions Between Controlled Foreign Corporation
and Shareholders or Other Related Persons

SCHEDULE M
(Form 5471)
(Rev. December 2005)
Department of the Treasury
Internal Revenue Service

䊳

Signature

OMB No. 1545-0704

Attach to Form 5471. See Instructions for Form 5471.
Identifying number

Name of person filing Form 5471

Name of foreign corporation

Important: Complete a separate Schedule M for each controlled foreign corporation. Enter the totals for each type of transaction that
occurred during the annual accounting period between the foreign corporation and the persons listed in columns (b) through (f). All amounts
must be stated in U.S. dollars translated from functional currency at the average exchange rate for the foreign corporation’s tax year. See
instructions.
Enter the relevant functional currency and the exchange rate used throughout this schedule 䊳
(a) Transactions
of
foreign corporation

1 Sales of
(inventory)

stock

in

(b) U.S. person
filing this return

(c) Any domestic
corporation or
partnership controlled
by U.S. person filing
this return

(d) Any other foreign
(e) 10% or more U.S. (f) 10% or more U.S.
corporation or
shareholder of controlled shareholder of any
partnership controlled
corporation
foreign corporation
by U.S. person filing
controlling the
(other than the U.S.
this return
person filing this return) foreign corporation

trade

2 Sales of property rights
(patents, trademarks, etc.)
3 Compensation received for technical, managerial, engineering,
construction, or like services
4 Commissions received
5 Rents, royalties, and license
fees received
6 Dividends received (exclude
deemed distributions under
subpart F and distributions of
previously taxed income)
7 Interest received
8 Premiums received for insurance or reinsurance
9 Add lines 1 through 8
10 Purchases of stock in trade
(inventory)
11 Purchases of tangible property
other than stock in trade
12 Purchases of property rights
(patents, trademarks, etc.)
13 Compensation paid for technical, managerial, engineering,
construction, or like services
14 Commissions paid
15 Rents, royalties, and license
fees paid
16 Dividends paid
17 Interest paid
18 Add lines 10 through 17
19 Amounts borrowed (enter the
maximum loan balance during
the year) — see instructions
20 Amounts loaned (enter the
maximum loan balance during
the year) — see instructions
For Paperwork Reduction Act Notice, see the Instructions for Form 5471.

Cat. No. 49963O

Schedule M (Form 5471) (Rev. 12-2005)