SCHEDULE PH OMB No. 1545-0123

(Form 1120) U.S. Personal Holding Company (PHC) Tax

Department of the Treasury

Internal Revenue Service

 See separate instructions. Attach to tax return.

Name Employer identification number

Undistributed Personal Holding Company Income (see instructions)

1 Taxable income before net operating loss deduction and special deductions. Enter amount

from Form 1120, line 28 1

2 Contributions deducted in figuring line 1. Enter amount from Form 1120, line 19 2

Excess expenses and depreciation under section 545(b)(6). Enter amount from Part V,

line 2

3

Additions

3

4 Total. Add lines 1 through 3 4

Federal and foreign income, war profits, and excess profits taxes not deducted in figuring

line 1 (attach schedule)

5

5

6 Contributions deductible under section 545(b)(2). See instructions for limitation 6

7 Net operating loss for the preceding tax year deductible under section 545(b)(4) 7

Net capital gain. Enter amount from Schedule D (Form 1120),

line 13. Foreign corporations, see instructions

8a

8a

Less: Income tax on this net capital gain (see section 545(b)(5))

(attach computation)

b

8b 8c

Deduction for dividends paid (other than dividends paid after the end of the tax year).

Enter amount from Part VI, line 5

9

9

Deductions

10 Total. Add lines 5 through 9 10

11 Subtract line 10 from line 4 11

12 Dividends paid after the end of the tax year (other than deficiency dividends defined in

section 547(d)), but not more than the smaller of line 11 or 20% of Part VI, line 1 12

Undistributed PHC income. Subtract line 12 from line 11. Foreign corporations, see

instructions

13

13

Note: If the information in Part II and Part IV is not submitted with the return, the limitation period for assessment and

collection of the PHC tax is any time within 6 years after the return is filed. See section 6501(f).

Personal Holding Company Income (see instructions)

14 Dividends 14

15a Interest 15a

b Less: Amounts excluded (attach schedule) 15b 15c

16 Royalties (other than mineral, oil, gas, or copyright royalties) 16

17 Annuities 17

18a Rents 18a

b Less: Adjustments to rents (attach schedule) 18b 18c

19a Mineral, oil, and gas royalties 19a

19b 19c

b Less: Adjustments to mineral, oil, and gas royalties (attach

schedule)

20 Copyright royalties 20

21 Produced film rents 21

22 Compensation received for use of corporation property by 25% or more shareholder 22

23 Amounts received under personal service contracts and from their sale 23

24 Amounts includible in taxable income from estates and trusts 24

25 PHC income. Add lines 14 through 24 25

Tax on Undistributed Personal Holding Company Income

26 PHC tax. Enter 15% of line 13 here and on Schedule J (Form 1120), line 9, or on the proper

line of the appropriate tax return 26

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Forms 1120 and 1120-A. Cat. No. 11465P Schedule PH (Form 1120) 2004

Part III

Part I

Part II

2004
Schedule PH (Form 1120) 2004 Page 2

Enter the names and addresses of the individuals who together owned, directly or indirectly, at any time

during the last half of the tax year, more than 50% in value of the outstanding stock of the corporation.

Stock Ownership Requirement Under Section 542(a)(2)

Highest percentage of shares

owned during last half of tax year (a) Name (b) Address

(c) Preferred (d) Common

% %

% %

% %

% %

% %

Excess of Expenses and Depreciation Over Income From Property Not Allowable

Under Section 545(b)(6) (see instructions for Part I, line 3)

(e) Repairs,

insurance, and

other expenses

(section 162)

(attach schedule)

(h) Excess

(col. (f) less

col. (g))

(g) Income from

rent or other

compensation

(f) Total of

columns (d)

and (e)

(c) Cost or

other basis

(b) Date

acquired

(a) Description of

property

(d) Depreciation

deduction

1

2 Total excess of expenses and depreciation over rent or other compensation. Add the amounts in column

(h). Enter the total here and on Part I, line 3

Note: Attach a statement showing the names and addresses of persons from whom rent or other

compensation was received for the use of, or the right to use, each property.

Deduction for Dividends Paid Under Sections 561 and 562

Taxable dividends paid. Do not include dividends considered as paid in the preceding tax

year under section 563 or deficiency dividends as defined in section 547

1

1

2 Consent dividends. Attach Forms 972 and 973 2

3 Taxable distributions. Add lines 1 and 2 3

4 Dividend carryover from first and second preceding tax years. Attach computation 4

Deduction for dividends paid. Add lines 3 and 4. Enter the total here and on Part I,

line 9

5

5

Add the amounts in columns (c) and (d) and enter the totals here  % %

Part IV

1

2

Part VI

Part V

Schedule PH (Form 1120) 2004