Annual Information Return of Foreign

Trust With a U.S. Owner Form 3520-A OMB No. 1545-0160

Department of the Treasury

Internal Revenue Service © See separate instructions.

Note: All information must be in English. Show all amounts in U.S. dollars.

For calendar year 2009, or tax year beginning , 2009, ending , 20 .

Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge

and belief, it is true, correct, and complete.

Title Date

Trustee’s

Signature

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 19595G Form 3520-A (2009)

Preparer’s SSN or PTIN Date

Preparer’s

Signature

General Information (see instructions)

1a Name of foreign trust b Employer identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

3a Name of U.S. agent b Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

4a Name of trustee b Identification number, if any

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

5 Did the trust transfer any property (including cash) to another person (see instructions for definition) during the tax

year? If “Yes,” attach statement (see instructions).

Part I

Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust

information?

If “Yes,” skip lines 2a through 2e and go to line 3.

Yes No

2

(Under section 6048(b))

Yes No

If “No,” you are required to attach a copy of all trust documents as indicated below. If these documents have been attached to a Form

3520-A filed within the previous 3 years, attach only relevant updates.

Have you attached a copy of:

a Summary of all written and oral agreements and understandings relating to the trust?

Yes No

Attached

Previously

Year

Attached

b The trust instrument?

c Memoranda or letters of wishes?

d Subsequent variances to original trust documents?

e Other trust documents?

Check appropriate boxes. Initial return Final return Amended return

6 Enter the number of Foreign Grantor Trust Owner Statements (page 3) included with this Form 3520-A ©

©

©

2009
Form 3520-A (2009) Page 2

Foreign Trust Income Statement

Enter totals from books and records of foreign trust (see instructions).

Income Expenses

Foreign Trust Balance Sheet Beginning of Tax Year End of Tax Year

(a) (b) (c) (d) Assets

Liabilities

Part II

1 Interest

2 Dividends

3 Gross rents and royalties 

5 Capital gains:

a Net short-term capital gain (loss)

b Net long-term capital gain (loss)

6 Ordinary gains (losses)

7 Other income (attach schedule)

8 Total income (add lines 1 through 7) 

9 Interest expense

10a Foreign taxes (attach schedule) 

b State and local taxes

11 Amortization and depreciation (depletion)

12 Trustee and advisor fees

13 Charitable contributions

14 Other expenses (attach schedule)

15 Total expenses (add lines 9 through 14)

16 Net income (loss) (subtract line 15 from line 8)

17a Enter the fair market value (FMV) of total distributions from the trust to all persons, whether U.S. or foreign ©

(i) Name of owner (ii) Identification number (iii) Date of distribution

Part III

3 Mortgages and notes receivable

1 Cash

2 Accounts receivable

4 Inventories

5 Government obligations

6 Other marketable securities

7 Other nonmarketable securities

8a Depreciable (depletable) assets

b Less: accumulated depreciation (depletion)

9 Real property

10 Other assets (attach schedule)

11 Total assets

12 Accounts payable

13 Contributions, gifts, grants, etc., payable

14 Mortgages and notes payable

15 Other liabilities (attach schedule) 

16 Total liabilities 

Net Worth

17 Contributions to trust corpus

18 Accumulated trust income

19 Other (attach schedule)

20 Total net worth (add lines 17 through 19)

21

4 Income (loss) from partnerships and fiduciaries 

Distributions to U.S. owners:

Distributions to U.S. beneficiaries:

b

c

(iv) FMV

(i) Name of beneficiary (ii) Identification number (iii) Date of distribution (iv) FMV

Total liabilities and net worth (add lines 16 and 20)

Form 3520-A (2009)
Form 3520-A (2009) Page 3

2009 Foreign Grantor Trust Owner Statement (see instructions)

1a Name of foreign trust b Employer identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

3a Name of U.S. agent b Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

4a Name of trustee b Identification number (if any)

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

5 The tax year of the owner of the foreign trust to which this statement relates ©

6a Name of U.S. owner b Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

9 Gross value of the portion of the trust treated as owned by the U.S. owner $

2009 Statement of Foreign Trust Income Attributable to U.S. Owner (see instructions)

1a Taxable interest 

2a Total ordinary dividends

3 Gross rents and royalties

5 Capital gains (losses)

6 Ordinary gains (losses)

7 Other income (attach schedule)

8 Interest expense 

9a Foreign taxes (attach schedule)

b State and local taxes

10 Amortization and depreciation (depletion)

11 Trustee and advisor fees

12 Charitable contributions

13 Other expenses (attach schedule) 

2 Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust information? Yes No

If “Yes,” complete lines 3a through 3g.

Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or

portion of the foreign trust) is treated for U.S. tax principles as owned by the U.S. person.

7

4 Income from partnerships and fiduciaries

Income Expenses

Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge

and belief, it is true, correct, and complete.

Trustee Signature © Title © Date ©

Report each item on the proper form or schedule of your tax return.

8 If the trust did not appoint a U.S. agent, list the trust documents attached to Form 3520-A (see instructions).

h Service Center where U.S. owner files its income tax returns ©

Important: Trustee must prepare a separate statement for each U.S. owner and include a copy of each statement with Form 3520-A. Trustee is also required

to send to each U.S. owner a copy of the owner’s statement. U.S. owner must attach a copy of its statement to Form 3520.

b Tax-exempt interest ©

b Qualified dividends ©
Form 3520-A (2009) Page 4

2009 Foreign Grantor Trust Beneficiary Statement

1a Name of foreign trust b Employer identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

3a Name of U.S. agent b Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

4a Name of trustee b Identification number (if any)

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

5 The first and last day of the tax year of the foreign trust to which Form 3520-A applies ©

6a Name of U.S. beneficiary b Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town e State or province f ZIP or postal code g Country

7 Description of property (including cash) distributed, or treated as distributed, to the U.S. person during the tax year. (See the instructions

for Part III of Form 3520 for U.S. tax treatment of these amounts.)

(a) Description of property (b) FMV

8 Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or

portion of the foreign trust) is treated for U.S. tax principles as owned by another person.

9 Owner of the foreign trust is (check one):

Individual Partnership Corporation

Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust

information? Yes No

If “Yes,” complete lines 3a through 3g.

2

Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge

and belief, it is true, correct, and complete.

Trustee Signature © Title © Date ©

Yes No

If “No,” do you agree that either the IRS or the U.S. beneficiary can inspect and copy the trust’s permanent books

of account, records, and such other documents that are necessary to establish that the trust should be treated for

U.S. tax purposes as owned by another person? 

Form 3520-A (2009)

Important: Trustee must prepare a separate statement for each U.S. beneficiary that received a distribution from the trust during the tax year and

include a copy of each statement with Form 3520-A. Trustee is also required to send to each such beneficiary a copy of the

beneficiary’s statement. U.S. beneficiary must attach a copy of its statement to Form 3520.