Form 5471 Information Return of U.S. Persons with Respect to Certa

Form

5471

(Rev. December 2007)
Department of the Treasury
Internal Revenue Service

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

OMB No. 1545-0704

© See separate instructions.
Information furnished for the foreign corporation’s annual accounting period (tax year required by
section 898) (see instructions) beginning
, 20
, and ending
, 20

Name of person filing this return

Attachment
Sequence No.

121

A Identifying number

Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address) B Category of filer (See instructions. Check applicable box(es)):

1 (repealed) 2
City or town, state, and ZIP code

3

4

5

C Enter the total percentage of the foreign corporation’s voting stock
you owned at the end of its annual accounting period

Filer’s tax year beginning
D

, 20

, and ending

%

, 20

Person(s) on whose behalf this information return is filed:
(1) Name

(2) Address

(4) Check applicable box(es)

(3) Identifying number

Shareholder

Officer

Director

Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be stated
in U.S. dollars unless otherwise indicated.
1a Name and address of foreign corporation

b Employer identification number, if any

c Country under whose laws incorporated

d Date of incorporation

2

e Principal place of business

f Principal business activity
code number

g Principal business activity

h Functional currency

Provide the following information for the foreign corporation’s accounting period stated above.
a Name, address, and identifying number of branch office or agent (if any) in
the United States

b If a U.S. income tax return was filed, enter:
(i) Taxable income or (loss)

c Name and address of foreign corporation’s statutory or resident agent in
country of incorporation

Schedule A

(ii) U.S. income tax paid
(after all credits)

d Name and address (including corporate department, if applicable) of
person (or persons) with custody of the books and records of the foreign
corporation, and the location of such books and records, if different

Stock of the Foreign Corporation
(b) Number of shares issued and outstanding
(a) Description of each class of stock

For Paperwork Reduction Act Notice, see instructions.

(i) Beginning of annual
accounting period

Cat. No. 49958V

(ii) End of annual
accounting period

Form

5471

(Rev. 12-2007)

Form 5471 (Rev. 12-2007)

Schedule B

Page

2

U.S. Shareholders of Foreign Corporation (see instructions)

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

(b) Description of each class of stock held by
shareholder. Note: This description should match the
corresponding description entered in Schedule A,
column (a).

(c) Number of
shares held at
beginning of
annual
accounting period

(d) Number of
shares held at
end of annual
accounting
period

(e) Pro rata share
of subpart F
income (enter as
a percentage)

Schedule C
Income Statement (see instructions)
Important: Report all information in functional currency in accordance with U.S. GAAP. Also, report each amount in
U.S. dollars translated from functional currency (using GAAP translation rules). However, if the functional currency is
the U.S. dollar, complete only the U.S. Dollars column. See instructions for special rules for DASTM corporations.

Deductions

Income

Functional Currency

1a
b
c
2
3
4
5
6a
b
7
8
9
10
11a
b
12
13
14
15
16

Net Income

17
18

19
20
21

Gross receipts or sales
Returns and allowances
Subtract line 1b from line 1a
Cost of goods sold
Gross profit (subtract line 2 from line 1c)
Dividends
Interest
Gross rents
Gross royalties and license fees
Net gain or (loss) on sale of capital assets
Other income (attach schedule)
Total income (add lines 3 through 8)
Compensation not deducted elsewhere
Rents
Royalties and license fees
Interest
Depreciation not deducted elsewhere
Depletion
Taxes (exclude provision for income, war profits, and excess profits taxes)
Other deductions (attach schedule—exclude provision for income, war profits,
and excess profits taxes)
Total deductions (add lines 10 through 16)
Net income or (loss) before extraordinary items, prior period adjustments, and
the provision for income, war profits, and excess profits taxes (subtract line
17 from line 9)
Extraordinary items and prior period adjustments (see instructions)
Provision for income, war profits, and excess profits taxes (see instructions)
Current year net income or (loss) per books (combine lines 18 through 20)

U.S. Dollars

1a
1b
1c
2
3
4
5
6a
6b
7
8
9
10
11a
11b
12
13
14
15
16
17

18
19
20
21
Form

5471

(Rev. 12-2007)

Form 5471 (Rev. 12-2007)

Schedule E

Page

3

Income, War Profits, and Excess Profits Taxes Paid or Accrued (see instructions)
Amount of tax
(a)
Name of country or U.S. possession

1
2
3
4
5
6
7

U.S.

8

Total

(b)
In foreign currency

(d)
In U.S. dollars

(c)
Conversion rate

©

Schedule F
Balance Sheet
Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See instructions
for an exception for DASTM corporations.
(a)
Beginning of annual
accounting period

Assets
1
2a
b
3
4
5
6
7
8a
b
9a
b
10
11
a
b
c
d
12

Cash
Trade notes and accounts receivable
Less allowance for bad debts
Inventories
Other current assets (attach schedule)
Loans to shareholders and other related persons
Investment in subsidiaries (attach schedule)
Other investments (attach schedule)
Buildings and other depreciable assets
Less accumulated depreciation
Depletable assets
Less accumulated depletion
Land (net of any amortization)
Intangible assets:
Goodwill
Organization costs
Patents, trademarks, and other intangible assets
Less accumulated amortization for lines 11a, b, and c
Other assets (attach schedule)

13

Total assets

1
2a
2b (
3
4
5
6
7
8a
8b (
9a
9b (
10
11a
11b
11c
11d (
12

(b)
End of annual
accounting period

)(

)

)(

)

)(

)

)(

)

)(

)

13

Liabilities and Shareholders’ Equity
14
15
16
17
18

Accounts payable
Other current liabilities (attach schedule)
Loans from shareholders and other related persons
Other liabilities (attach schedule)
Capital stock:
a Preferred stock
b Common stock
19 Paid-in or capital surplus (attach reconciliation)
20 Retained earnings
21 Less cost of treasury stock
22

Total liabilities and shareholders’ equity

14
15
16
17
18a
18b
19
20
21 (
22
Form

5471

(Rev. 12-2007)

Form 5471 (Rev. 12-2007)

Schedule G

Page

4

Other Information
Yes No

1

2
3

4
5

During the tax year, did the foreign corporation own at least a 10% interest, directly or indirectly, in any foreign
partnership?
If “Yes,” see the instructions for required attachment.
During the tax year, did the foreign corporation own an interest in any trust?
During the tax year, did the foreign corporation own any foreign entities that were disregarded as entities separate
from their owners under Regulations sections 301.7701-2 and 301.7701-3 (see instructions)?
If “Yes,” you are generally required to attach Form 8858 for each entity (see instructions).
During the tax year, was the foreign corporation a participant in any cost sharing arrangement?
During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?

Schedule H
Current Earnings and Profits (see instructions)
Important: Enter the amounts on lines 1 through 5c in functional currency.
1

Current year net income or (loss) per foreign books of account

2

Net adjustments made to line 1 to determine current
earnings and profits according to U.S. financial and tax
accounting standards (see instructions):

a
b
c
d
e
f
g
h
3
4
5a
b
c
d

1
Net
Additions

Net
Subtractions

Capital gains or losses
Depreciation and amortization
Depletion
Investment or incentive allowance
Charges to statutory reserves
Inventory adjustments
Taxes
Other (attach schedule)
Total net additions
Total net subtractions
Current earnings and profits (line 1 plus line 3 minus line 4)
DASTM gain or (loss) for foreign corporations that use DASTM (see instructions)
Combine lines 5a and 5b
Current earnings and profits in U.S. dollars (line 5c translated at the appropriate exchange rate as
defined in section 989(b) and the related regulations (see instructions))
Enter exchange rate used for line 5d ©

Schedule I

5a
5b
5c
5d

Summary of Shareholder’s Income From Foreign Corporation (see instructions)

1

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

1

2
3

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

2

5

Factoring income

5

6

Total of lines 1 through 5. Enter here and on your income tax return. See instructions

6

7

Dividends received (translated at spot rate on payment date under section 989(b)(1))

7

8

Exchange gain or (loss) on a distribution of previously taxed income

8

4

3
4

Yes No
● Was any income of the foreign corporation blocked?
● Did any such income become unblocked during the tax year (see section 964(b))?
If the answer to either question is “Yes,” attach an explanation.
Form

5471

(Rev. 12-2007)