5471 Information Return of U.S. Persons With Respect to Certa

Version A, Cycle 4

Form

5471

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

(Rev. December 2022)

OMB No. 1545-0123

Go to www.irs.gov/Form5471 for instructions and the latest information.

Department of the Treasury
Internal Revenue Service

Attachment
Sequence No.

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

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).):

1a
City or town, state, and ZIP code

1b

1c

2

3

4

5a

5b

121

5c

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

, 20

, and ending

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, 20

F Check the box if this Form 5471 has been completed using “Alternative Information” under Rev. Proc. 2019-40

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G If the box on line F is checked, enter the corresponding code for “Alternative Information” (see instructions) .

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D Check box if this is a final Form 5471 for the foreign corporation

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E Check if any excepted specified foreign financial assets are reported on this form (see instructions)

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H 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

INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022

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 code

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. 12-2022)

Version A, Cycle 4
Page 2

Form 5471 (Rev. 12-2022)

Schedule B Shareholders of Foreign Corporation
Part I
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
(d) Number of
shares held at
shares held at
beginning of annual
end of annual
accounting period accounting period

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

INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022

Part II

Direct Shareholders of Foreign Corporation (see instructions)

(a) Name, address, and identifying number of shareholder.
Also, include country of incorporation
or formation, if applicable.

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

Form 5471 (Rev. 12-2022)

Version A, Cycle 4
Page 3
Schedule C Income Statement (see instructions)
Important: Report all information in functional currency in accordance with U.S. generally accepted accounting
principles (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 dollar approximate separate transactions method (DASTM) corporations.
Form 5471 (Rev. 12-2022)

Income

Functional Currency

1a
b
c
2
3
4
5
6a
b
7
8a
b
9
10
11
12a
b
13
14
15
16
17
18

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 . . . . . . . . . . .
Foreign currency transaction gain or loss—unrealized
. . . . . .
Foreign currency transaction gain or loss—realized . . . . . . .
Other income (attach statement)
. . . . . . . . . . . . .
Total income (add lines 3 through 9) . . . . . . . . . . . .
Compensation not deducted elsewhere . . . . . . . . . . .
Rents . . . . . . . . . . . . . . . . . . . . . .
Royalties and license fees . . . . . . . . . . . . . . . .
Interest . . . . . . . . . . . . . . . . . . . . . .
Depreciation not deducted elsewhere . . . . . . . . . . . .
Depletion . . . . . . . . . . . . . . . . . . . . .
Taxes (exclude income tax expense (benefit)) . . . . . . . . .
Other deductions (attach statement—exclude income tax expense (benefit))
Total deductions (add lines 11 through 17) . . . . . . . . . .

19

Net income or (loss) before unusual or infrequently occurring items, and
income tax expense (benefit) (subtract line 18 from line 10) . . . . .
Unusual or infrequently occurring items . . . . . . . . . . .
Income tax expense (benefit)—current . . . . . . . . . . . .
Income tax expense (benefit)—deferred . . . . . . . . . . .
Current year net income or (loss) per books (combine lines 19 through 21b)
Foreign currency translation adjustments . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . .
Income tax expense (benefit) related to other comprehensive income .
Other comprehensive income (loss), net of tax (line 23a plus line 23b less
line 23c)
. . . . . . . . . . . . . . . . . . . . .

U.S. Dollars

1a
1b
1c
2
3
4
5
6a
6b
7
8a
8b
9
10
11
12a
12b
13
14
15
16
17
18

Other
Comprehensive
Income

Net Income

Deductions

INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022
20
21a
b
22
23a
b
c
24

19
20
21a
21b
22
23a
23b
23c
24

Form 5471 (Rev. 12-2022)

Version A, Cycle 4
Page 4
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.
Form 5471 (Rev. 12-2022)

(a)
Beginning of annual
accounting period

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

Cash . . . . . . . . . . . . . . . . . .
Trade notes and accounts receivable . . . . . . . .
Less allowance for bad debts . . . . . . . . . .
Derivatives . . . . . . . . . . . . . . . .
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 12a, 12b, and 12c
Other assets (attach statement) . . . . . . . . . .
Total assets . . . . . . . . . . . . . . . .

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

(b)
End of annual
accounting period

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INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022
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12a
12b
12c
12d (
13
14

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Liabilities and Shareholders’ Equity

15
16
17
18
19
20
a
b
21
22
23
24

Accounts payable . . . . . . . . . . .
Other current liabilities (attach statement) . . .
Derivatives . . . . . . . . . . . . .
Loans from shareholders and other related persons
Other liabilities (attach statement) . . . . . .
Capital stock:
Preferred stock . . . . . . . . . . . .
Common stock . . . . . . . . . . . .
Paid-in or capital surplus (attach reconciliation) .
Retained earnings . . . . . . . . . . .
Less cost of treasury stock . . . . . . . .
Total liabilities and shareholders’ equity . . . .

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15
16
17
18
19

20a
20b
21
22
23 (
24

Schedule G Other Information
Yes No
1

2
3

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.
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 separate from
their owner under Regulations sections 301.7701-2 and 301.7701-3 or did the foreign corporation own any foreign
branches (see instructions)?
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” you are generally required to attach Form 8858 for each entity or branch (see instructions).

4a

During the tax year, did the filer pay or accrue any base erosion payment under section 59A(d) to the foreign
corporation or did the filer have a base erosion tax benefit under section 59A(c)(2) with respect to a base erosion
payment made or accrued to the foreign corporation (see instructions)? . . . . . . . . . . . . . .
If “Yes,” complete lines 4b and 4c.
b Enter the total amount of the base erosion payments . . . . . . . . . . . . . $
c Enter the total amount of the base erosion tax benefits . . . . . . . . . . . . . $
5a During the tax year, did the foreign corporation pay or accrue any interest or royalty for which the deduction is not
allowed under section 267A? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” complete line 5b.
b Enter the total amount of the disallowed deductions (see instructions) . . . . . . . . $
Form 5471 (Rev. 12-2022)

Version A, Cycle 4
Page 5

Form 5471 (Rev. 12-2022)

Schedule G Other Information (continued)
Yes No
6a

Is the filer claiming a foreign-derived intangible income (FDII) deduction (under section 250) with respect to any
transactions with the foreign corporation? . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” complete lines 6b, 6c, and 6d. See instructions.
b Enter the amount of gross receipts derived from all sales of general property to the foreign corporation that the
filer included in its computation of foreign-derived deduction eligible income (FDDEI) . . . $
c Enter the amount of gross receipts derived from all sales of intangible property to the foreign corporation that the
filer included in its computation of FDDEI . . . . . . . . . . . . . . . . . $
d Enter the amount of gross receipts derived from all services provided to the foreign corporation that the filer
included in its computation of FDDEI . . . . . . . . . . . . . . . . . . . $
7
During the tax year, was the foreign corporation a participant in any cost sharing arrangement? . . . . . .
If the answer to question 7 is “Yes,” complete a separate Schedule G-1 for each cost sharing arrangement in
which the foreign corporation was a participant during the tax year.
8

From April 25, 2014, to December 31, 2017, did the foreign corporation purchase stock or securities of a
shareholder of the foreign corporation for use in a triangular reorganization (within the meaning of Regulations
section 1.358-6(b)(2))?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 a Did the foreign corporation receive any intangible property in a prior year or the current tax year for which the U.S.
transferor is required to report a section 367(d) annual income inclusion for the tax year? . . . . . . . .
If “Yes,” go to line 9b.
b Enter in functional currency the amount of the earnings and profits reduction pursuant to section 367(d)(2)(B) for
the tax year . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
During the tax year, was the foreign corporation an expatriated foreign subsidiary under Regulations section
1.7874-12(a)(9)?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” see instructions and attach statement.
11
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).
12
During the tax year, did the foreign corporation pay or accrue any foreign tax that was disqualified for credit under
section 901(m)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
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? . . . . . . . .
14
Did you answer “Yes” to any of the questions in the instructions for line 14? . . . . . . . . . . . . .
If “Yes,” enter the corresponding code(s) from the instructions and attach statement
Does the foreign corporation have interest expense disallowed under section 163(j) (see instructions)? . . . .
15
If “Yes,” enter the amount . . . . . . . . . . . . . . . . . . . . . . $
16
Does the foreign corporation have previously disallowed interest expense under section 163(j) carried forward to
the current tax year (see instructions)? . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” enter the amount . . . . . . . . . . . . . . . . . . . . . . $
17a Did any extraordinary reduction with respect to a controlling section 245A shareholder occur during the tax year
(see instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b If the answer to question 17a is “Yes,” was an election made to close the tax year such that no amount is treated
as an extraordinary reduction amount or tiered extraordinary reduction amount (see instructions)? . . . . .
18
Does the reporting corporation have any loan to or from the related party to which the safe-haven rate rules of
Regulations section 1.482-2(a)(2)(iii)(B) are applicable, and for which the reporting corporation used a rate of
interest within the safe-haven range of Regulations section 1.482-2(a)(2)(iii)(B)(1) (100% to 130% of the AFR for the
relevant term)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022

19a

Did the reporting corporation make at least one distribution or acquisition (as defined by Regulations section
1.385-3) during the period including the tax year and the preceding 3 tax years, or, during the period beginning 36
months before the date of the respective distribution or acquisition and ending 36 months afterward, did the
reporting corporation issue or refinance indebtedness owed to a related party? . . . . . . . . . . . .

b If the answer to question 19a is “Yes,” provide the following.
(1) The amount of such distribution(s) and acquisition(s) . .
(2) The amount of such related party indebtedness . . . .

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Form 5471 (Rev. 12-2022)

Version A, Cycle 4
Page 6

Form 5471 (Rev. 12-2022)

Schedule I

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

If item H on page 1 is completed, a separate Schedule I must be filed for each Category 4, 5a, or 5b filer for whom reporting is
furnished on this Form 5471. This Schedule I is being completed for:
Name of U.S. shareholder
Identifying number
1a Section 964(e)(4) subpart F dividend income from the sale of stock of a lower-tier foreign corporation
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Section 245A(e)(2) subpart F income from hybrid dividends of tiered corporations (see instructions) .
c Subpart F income from tiered extraordinary disposition amounts not eligible for subpart F exception
under section 954(c)(6) . . . . . . . . . . . . . . . . . . . . . . . . . .
d Subpart F income from tiered extraordinary reduction amounts not eligible for subpart F exception
under section 954(c)(6) . . . . . . . . . . . . . . . . . . . . . . . . . .
e Section 954(c) Subpart F Foreign Personal Holding Company Income (enter result from Worksheet A)
f Section 954(d) Subpart F Foreign Base Company Sales Income (enter result from Worksheet A) . .
g Section 954(e) Subpart F Foreign Base Company Services Income (enter result from Worksheet A) .
h Other subpart F income (enter result from Worksheet A) . . . . . . . . . . . . . . .
2
Earnings invested in U.S. property (enter the result from Worksheet B) . . . . . . . . . . .
3
Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Factoring income . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See instructions for reporting amounts on lines 1, 2, and 4 on your income tax return.
5a Section 245A eligible dividends (see instructions) . . . . . . . . . . . . . . . . . .
b Extraordinary disposition amounts (see instructions) . . . . . . . . . . . . . . . . .
c Extraordinary reduction amounts (see instructions) . . . . . . . . . . . . . . . . .
d Section 245A(e) dividends (see instructions). . . . . . . . . . . . . . . . . . . .
e Dividends not reported on line 5a, 5b, 5c, or 5d . . . . . . . . . . . . . . . . . .
6
Exchange gain or (loss) on a distribution of previously taxed earnings and profits . . . . . . .

1a
1b
1c
1d
1e
1f
1g
1h
2
3
4

INTERNAL USE ONLY
DRAFT AS OF
April 29, 2022
5a
5b
5c
5d
5e
6

Yes No

7a Was any income of the foreign corporation blocked? . . . . . . . . . .
b 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.
8a

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Did this U.S. shareholder have an extraordinary disposition (ED) account with respect to the foreign corporation at
any time during the tax year (see instructions)? . . . . . . . . . . . . . . . . . . . . . .
b If the answer to question 8a is “Yes,” enter the U.S. shareholder’s ED account balance at the beginning of the CFC year
. Provide an attachment detailing any changes from the
$
and at the end of the tax year $
beginning to the ending balances.
c Enter the CFC’s aggregate ED account balance with respect to all U.S. shareholders at the beginning of the CFC year
. Provide an attachment detailing any changes from the
$
and at the end of the tax year $
beginning to the ending balances.
Enter the sum of the hybrid deduction accounts with respect to stock of the foreign corporation (see instructions) $
9
Form 5471 (Rev. 12-2022)