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 O FORM 5471, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ")
279mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

SCHEDULE O
(Form 5471)

Action

Date

O.K. to print
Revised proofs
requested

Organization or Reorganization of Foreign
Corporation, and Acquisitions and
Dispositions of its Stock

(Rev. December 2005)
Department of the Treasury
Internal Revenue Service

Signature

OMB No. 1545-0704

䊳 Attach to Form 5471. See Instructions for Form 5471.

Name of person filing Form 5471

Identifying number

Name of foreign corporation

Important: Complete a separate Schedule O for each foreign corporation for which information must be reported.

Part I

To Be Completed by U.S. Officers and Directors

(a)
Name of shareholder for whom
acquisition information is reported

Part II

(b)
Address of shareholder

(c)
Identifying number
of shareholder

(d)
Date of original
10% acquisition

(e)
Date of additional
10% acquisition

To Be Completed by U.S. Shareholders
Note: If this return is required because one or more shareholders became U.S. persons, attach a list showing the
names of such persons and the date each became a U.S. person.
Section A—General Shareholder Information

(a)
Name, address, and identifying number of
shareholder(s) filing this schedule

(b)
For shareholder’s latest U.S. income tax return filed, indicate:
(1)
Type of return
(enter form number)

(2)
Date return filed

(c)
Date (if any) shareholder
last filed information
return under section 6046
for the foreign corporation

(3)
Internal Revenue Service Center
where filed

Section B—U.S. Persons Who Are Officers or Directors of the Foreign Corporation
(a)
Name of U.S. officer or director

(b)
Address

(c)
Social security number

(d)
Check appropriate
box(es)
Officer
Director

Section C—Acquisition of Stock
(a)

(b)

(c)

(d)

Name of shareholder(s) filing this schedule

Class of stock
acquired

Date of
acquisition

Method of
acquisition

For Paperwork Reduction Act Notice, see the Instructions for Form 5471.

Cat. No. 61200O

(e)
Number of shares acquired
(1)
Directly

(2)
Indirectly

(3)
Constructively

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

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE O (FORM 5471), PAGE 2 of 2
PRINTS: HEAD to HEAD
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄2 ")
279mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

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

Page

(f)
Amount paid or value given

2

(g)
Name and address of person from whom shares were acquired

Section D—Disposition of Stock

(a)
Name of shareholder disposing of stock

(f)
Amount received

(b)
Class of stock

(c)
Date of disposition

(d)
Method
of disposition

(e)
Number of shares disposed of
(1)
Directly

(2)
Indirectly

(3)
Constructively

(g)
Name and address of person to whom disposition of stock was made

Section E—Organization or Reorganization of Foreign Corporation
(a)
Name and address of transferor

(b)
Identifying number (if any)

(d)
Assets transferred to foreign corporation
(1)
Description of assets

(2)
Fair market value

(c)
Date of transfer

(e)
(3)
Adjusted basis (if transferor
was U.S. person)

Description of assets transferred by, or notes or
securities issued by, foreign corporation

Section F—Additional Information
(a) If the foreign corporation or a predecessor U.S. corporation filed (or joined with a consolidated group in filing) a U.S. income tax return
for any of the last 3 years, attach a statement indicating the year for which a return was filed (and, if applicable, the name of the corporation
filing the consolidated return), the taxable income or loss, and the U.S. income tax paid (after all credits).
(b) List the date of any reorganization of the foreign corporation that occurred during the last 4 years while any U.S. person held 10% or
more in value or vote (directly or indirectly) of the corporation’s stock 䊳
(c) If the foreign corporation is a member of a group constituting a chain of ownership, attach a chart, for each unit of which a shareholder
owns 10% or more in value or voting power of the outstanding stock. The chart must indicate the corporation’s position in the chain of
ownership and the percentages of stock ownership (see instructions for an example).
Schedule O (Form 5471) (Rev. 12-2005)