Schedule N (5471) Return of Officers, Directors, and 10% or More Sharehold

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SCHEDULE N
(Form 5471)

Action

Date

O.K. to print
Revised proofs
requested

Return of Officers, Directors, and 10% or More
Shareholders of a Foreign Personal Holding Company

(Rev. December 2004)
Department of the Treasury
Internal Revenue Service

䊳

Signature

OMB No. 1545-0704

Attach to Form 5471. See Instructions for Form 5471.

Name of person filing Form 5471

Identifying number

Name of foreign corporation

Important: All amounts must be stated in U.S. dollars translated from functional currency. See page 11 of the instructions for the
relevant exchange rate.
Enter the relevant functional currency and the exchange rate(s) used throughout this schedule 䊳

Part I
Shareholder Information
Section A—Outstanding Securities Convertible Into Stock of the Corporation or Options Granted by the Corporation
Face value

Interest
rate (%)

Description of securities (attach a complete, detailed statement of conversion privileges)

Beginning of year

End of year

Section B—List of Holders of Convertible Securities or Options Granted by the Corporation
Name and address of each holder
of convertible securities or options
(designate nonresident aliens)

Part II
1
2
3
4

Class
of
securities

Securities held
Beginning of year
Number

Face value

Explanation and date of
any change in holdings of
securities during the year

End of year
Number

Face value

Income Information
Section A—Undistributed Foreign Personal Holding Company Income
1
2
3

Gross income as defined in section 555 (attach schedule)
Deductions allowable under section 161 (attach schedule)
Taxable income or (loss) (subtract line 2 from line 1)
Adjustments to taxable income or (loss) (see page 12 of instructions):
Taxes (see instructions)
Charitable contributions
Special deductions disallowed
Net operating loss
Expenses and depreciation applicable to property of the taxpayer
Taxes and contributions to pension trusts
Total adjustments (combine lines 4a through 4f)
Combine line 3 and line 4g

a
b
c
d
e
f
g
5
6 Deduction for dividends paid during tax year. Enter the amount from Section B, line 12, below
7 Subtract line 6 from line 5
8 Deduction allowed under section 563(c) for dividends paid after close of tax year (see
instructions). Attach designation required by Rev. Proc. 90-26, 1990-1 C.B. 512
9 Undistributed foreign personal holding company income (subtract line 8 from line 7)

4a
4b
4c
4d
4e
4f
4g
5
6
7
8
9

Section B—Deduction for Dividends Paid During Tax Year (see instructions)
Date paid
10 Taxable dividends paid during tax year:
a Cash
b Property other than cash or the corporation’s own securities
(indicate nature of property)
c Obligations of the corporation (bonds, notes, scrip, etc.)
11 Consent dividends (attach schedule)
12 Deduction for dividends paid during tax year (add lines 10a through 11). Enter here and on line 6 above

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

Cat. No. 61925Q

Amount

10a
10b
10c
11
12

Schedule N (Form 5471) (Rev. 12-2004)