Schedule O (Form 5 Organization or Reorganization of Foreign Corporation, a

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

SCHEDULE O
(Form 5471)
(Rev. December 2012)

OMB No. 1545-0704

Information about Schedule O (Form 5471) and its instructions is at www.irs.gov/form5471
Department of the Treasury
▶ Attach to Form 5471.
Internal Revenue Service
Name of person filing Form 5471
Identifying number
Name of foreign corporation

EIN (if any)

Reference ID number (see instructions)

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

Part I

Part II

To Be Completed by U.S. Officers and Directors

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

(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)

(3)
Internal Revenue Service Center
where filed

(2)
Date return 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

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

(d)
Check appropriate
box(es)

Officer

Director

Section C—Acquisition of Stock
(a)
Name of shareholder(s) filing this schedule

(b)
Class of stock
acquired

(c)
Date of
acquisition

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

(d)
Method of
acquisition

Cat. No. 61200O

(e)
Number of shares acquired
(1)
Directly

(2)
Indirectly

(3)
Constructively

Schedule O (Form 5471) (Rev. 12-2012)

Schedule O (Form 5471) (Rev. 12-2012)

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

(b)
Class of stock

(c)
Date of disposition

(f)
Amount received

(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

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

(c)
Date of transfer

(e)
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 ▶
(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. 12-2012)