SCHEDULE S Exclusion of Income From the International OMB No. 1545-0126

(Form 1120-F) Operation of Ships or Aircraft Under Section 883

© Attach to Form 1120-F. Department of the Treasury

Internal Revenue Service

Name of corporation Employer identification number

Qualified Foreign Corporation

Part I

1a

b Check one (and only one) of the following boxes to indicate the type of equivalent exemption granted by the foreign

country listed on line 1a above:

2

a

d

Enter the name of the qualified foreign country in which the foreign corporation was organized ©

e

Note. If an amount is not readily determinable, enter a reasonable estimate. If an estimate is used on any of the lines

below, check here ©

Incidental container-related income

Income from the carriage of passengers and cargo

Incidental bareboat charter income of a ship or incidental dry lease income of an aircraft

Enter the gross income in each of the following categories of qualified income for which the exemption is being claimed:

2a

2b

2c

2009

Domestic law

Exchange of notes

Income tax convention

c Enter the applicable authority (i.e., the specific provision) of the equivalent exemption type indicated on line 1b (see

instructions) ©

b Time or voyage (full) charter income of a ship or wet lease income of an aircraft

c Bareboat charter income of a ship or dry lease income of an aircraft

f Income incidental to the international operation of ships or aircraft other than incidental income

included on lines 2d and 2e above

g Capital gains derived by a qualified foreign corporation engaged in the international operation of

ships or aircraft from the sale, exchange or other disposition of a ship, aircraft, container or

related equipment or other moveable property used by that qualified foreign corporation in the

international operation of ships or aircraft

h Income from participation in a pool, partnership, strategic alliance, joint operating agreement,

code-sharing arrangement, international operating agency, or other joint venture described in

Regulations section 1.883-1(e)(2)

Stock ownership test of Regulations section 1.883-1(c)(2):

3 Check one (and only one) of the following boxes to indicate the test under which the stock ownership test of Regulations

section 1.883-1(c)(2) was satisfied:

The publicly-traded test of Regulations section 1.883-2(a). Complete Part II.

The CFC stock ownership test of Regulations section 1.883-3(a). Complete Part III.

The qualified shareholder stock ownership test of Regulations section 1.883-4(a). Complete Part IV.

4 Check the box if any of the shares of the foreign corporation’s stock or the stock of any direct, indirect, or constructive

shareholder are issued in bearer form

5 If the box on line 4 is checked, check the box on this line 5 if none of the bearer shares were relied on to satisfy any of the

stock ownership tests described in Regulations section 1.883-1(c)(2)

Part II

6 Enter the name of the country in which the stock is primarily traded ©

Stock Ownership Test for Publicly-Traded Corporations

7 Enter the name of the securities market(s) on which the stock is listed ©

8 Enter a description of each class of stock relied on to meet the “regularly traded test” of Regulations section 1.883-2(d)

(see instructions for description requirements) ©

9 Do one or more 5% shareholders (see instructions for definition) own in the aggregate 50% or more 

of the vote and value of the outstanding shares of any class of stock for more than half the number of days during 

the tax year?

a The days during the tax year of the corporation in which the class of stock was closely held, without regard to the

exception in Regulations section 1.883-2(d)(3)(ii) ©

2d

2f

2g

2h

2e

10 For each class of stock relied on to meet the “regularly traded test” of Regulations section 1.883-2(d), indicate:

Yes No

If “Yes,” complete line 10.

If “No,” skip line 10.

(i)

(ii) The total percentage of the vote and value of the class of stock that is owned by 5% shareholders during 

such days © %
Schedule S (Form 1120-F) 2009 Page 2

Schedule S (Form 1120-F) 2009

Part IV Qualified Shareholder Stock Ownership Test

b For all qualified shareholders on which the corporation intends to rely to satisfy the closely-held exception test of

Regulations section 1.883-2(d)(3), and who own stock in the closely-held block (directly, indirectly, or by applying the

attribution rules of Regulations section 1.883-4(c)), enter:

(i) The total number of qualified shareholders, as defined in Regulations section 1.883-4(b)(1) ©

(ii) The total percentage of the value of the shares of the class of stock owned, directly or indirectly, by such qualified

shareholders by country of residence (see instructions):

Country code (see instructions) Percentage

(iii) The days during the tax year of the corporation that such qualified shareholders owned, directly or indirectly, their shares

in the closely-held block of stock ©

Part III Stock Ownership Test for Controlled Foreign Corporations

11 Enter the percentage of the value of the shares of the CFC that is owned by all “qualified U.S. persons” identified in the

qualified ownership statements required under Temporary Regulations section 1.883-3T(c)(2), applying the attribution of

ownership rules of Temporary Regulations section 1.883-3T(b)(4) © %

12 Enter the period during which such qualified U.S. persons held such stock (see instructions) ©

13 Enter the period during which the foreign corporation was a CFC (see instructions) ©

a Enter the total number of such qualified shareholders as defined in Regulations section 1.883-4(b)(1) ©

Country code (see instructions) Percentage

15 Check the box if more than 50% of the value of the outstanding shares of the corporation is owned (or treated as owned

by reason of Regulations section 1.883-4(c)) by qualified shareholders for each category of income for which the

exemption is claimed

16 With respect to all qualified shareholders relied on to satisfy the 50% ownership test of Regulations section 1.883-4(a):

b Enter the total percentage of the value of the outstanding shares owned, applying the attribution rules of Regulations

section 1.883-4(c), by such qualified shareholders by country of residence or organization, whichever is applicable:

c Enter the period during the tax year of the foreign corporation that such stock was held by qualified shareholders ©

14 Is the CFC directly held by qualified U.S. persons? Yes No