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

Form

5471

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

(Rev. December 2012)
Department of the Treasury
Internal Revenue Service

OMB No. 1545-0704

▶ For more information about Form 5471, see www.irs.gov/form5471
Information furnished for the foreign corporation’s annual accounting period (tax year required by
section 898) (see instructions) beginning
, 20
, and ending
, 20

Attachment
Sequence No.

Name of person filing this return

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1 (repealed)
City or town, state, and ZIP code
Filer’s tax year beginning

2

3

4

121

5

C Enter the total percentage of the foreign corporation’s voting
stock you owned at the end of its annual accounting period
, 20

, and ending

%

, 20

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

(2) Address

(3) Identifying number

(4) Check applicable box(es)
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(1) Employer identification number, if any
b(2) Reference ID number (see instructions)
c

d Date of incorporation

e Principal place of business

f Principal business activity
code number

Country under whose laws incorporated

g Principal business activity

h Functional currency

2 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:

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

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

(i) Taxable income or (loss)

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

Schedule A 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. 12-2012)

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Form 5471 (Rev. 12-2012)

Schedule B 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.

Net Income

Deductions

Income

Functional Currency

1a
b
c
2
3
4
5
6a
b
7
8
9

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 statement) . . . . . . . . . . . . . . . .
Total income (add lines 3 through 8) . . . . . . . . . . . . . . .
10
Compensation not deducted elsewhere
. . . . . . . . . . . . .
11a Rents . . . . . . . . . . . . . . . . . . . . . . . . .
b Royalties and license fees . . . . . . . . . . . . . . . . . .
12
Interest . . . . . . . . . . . . . . . . . . . . . . . .
13
Depreciation not deducted elsewhere . . . . . . . . . . . . . .
14
Depletion
. . . . . . . . . . . . . . . . . . . . . . .
15
Taxes (exclude provision for income, war profits, and excess profits taxes) . .
16
Other deductions (attach statement—exclude provision for income, war profits,
and excess profits taxes) . . . . . . . . . . . . . . . . . .
17
Total deductions (add lines 10 through 16) . . . . . . . . . . . . .
18
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) . . . . . . . . . . . . . . . . . . . . . . .
19
20
21

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. 12-2012)

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Form 5471 (Rev. 12-2012)

Schedule E Income, War Profits, and Excess Profits Taxes Paid or Accrued (see instructions)
Amount of tax

(a)
Name of country or U.S. possession

(b)
In foreign currency

(c)
Conversion rate

(d)
In U.S. dollars

1 U.S.
2
3
4
5
6
7
8 Total

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▶

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 statement) . . . . .
Loans to shareholders and other related persons . .
Investment in subsidiaries (attach statement) . . .
Other investments (attach statement) . . . . . .
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 statement) . . . . . . . .

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1
2a
2b (
3
4
5
6
7
8a
8b (
9a
9b (
10

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11a
11b
11c
11d (
12

13

Total assets .

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13

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14
15
16
17

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(b)
End of annual
accounting period

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Liabilities and Shareholders’ Equity
14
15
16
17
18
a
b
19
20
21

Accounts payable . . . . . . . .
Other current liabilities (attach statement)

22

Total liabilities and shareholders’ equity . . . . . . . . . . . . . . . .

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Loans from shareholders and other related persons .

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Other liabilities (attach statement) . . . . .
Capital stock:
Preferred stock . . . . . . . . . . .
Common stock . . . . . . . . . . .
Paid-in or capital surplus (attach reconciliation)
Retained earnings . . . . . . . . . .
Less cost of treasury stock . . . . . . .

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18a
18b
19
20
21 (
22

Form 5471 (Rev. 12-2012)

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Form 5471 (Rev. 12-2012)

Schedule G Other Information
Yes No
1 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 statement.
2 During the tax year, did the foreign corporation own an interest in any trust? . . . . . . . . . . . . . .
3 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).
4 During the tax year, was the foreign corporation a participant in any cost sharing arrangement? . . . . . . . .
5 During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?
6 During the tax year, did the foreign corporation participate in any reportable transaction as defined in Regulations
section 1.6011-4?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” attach Form(s) 8886 if required by Regulations section 1.6011-4(c)(3)(i)(G).
7 During the tax year, did the foreign corporation pay or accrue any foreign tax that was disqualified for credit under
section 901(m)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 During the tax year, did the foreign corporation pay or accrue foreign taxes to which section 909 applies, or treat
foreign taxes that were previously suspended under section 909 as no longer suspended? . . . . . . . .

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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
Net
Net
profits according to U.S. financial and tax accounting standards
Additions
Subtractions
(see instructions):
Capital gains or losses . . . . . . . . . . . . . .
Depreciation and amortization . . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . .
Investment or incentive allowance . . . . . . . . . . .
Charges to statutory reserves . . . . . . . . . . . .
Inventory adjustments . . . . . . . . . . . . . . .
Taxes . . . . . . . . . . . . . . . . . . . .
Other (attach statement) . . . . . . . . . . . . . .
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 ▶

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

Schedule I

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1

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5a
5b
5c
5d

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

If item D on page 1 is completed, a separate Schedule I must be filed for each Category 4 or 5 filer for whom reporting is furnished on
this Form 5471. This schedule I is being completed for:
Name of U.S. shareholder ▶
Identifying number ▶
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) . . . . . . . . .
3
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,
4
Worksheet D in the instructions) . . . . . . . . . . . . . . . . . . . . . . .
5
Factoring income . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Total of lines 1 through 5. Enter here and on your income tax return. See instructions . . . . . .
7
Dividends received (translated at spot rate on payment date under section 989(b)(1)) . . . . . .
8
Exchange gain or (loss) on a distribution of previously taxed income . . . . . . . . . . .

1
2
3
4
5
6
7
8
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.

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Form 5471 (Rev. 12-2012)