Form 5713 (5-77)

Page 4

Requests for and Acts of Participation in or Cooperation with an International Boycott

12 (a) Did you receive requests to enter into, or, in fact, enter into any agreement: Requests | Agreements
Type of participation or cooperation Yes |_No | Yes |_No
(1) As a condition of doing business directly or indirectly within a country or with the government,
a company, or a national of a country to— .
(i) Refrain from doing business with or in a country which is the object of an international
boycott or with the government, companies or nationals of that country? a es a
(ii) Refrain from doing business with any United States person engaged in trade in a country
which is the object of an international boycott or with the government, companies, or
nationals of that country? . . . - . |__| —_|__
(iii) Refrain from doing business with any company whose ownership or management is made
up, all or in part, of individuals of a particular nationality, race, or religion, or to remove
(or refrain from selecting) corporate directors who are individuals of a particular nationality,
race, or religion??. . . . . - toe ee ee er ee
(iv) Refrain from employing individuals of a ‘particular nationality, race, or religion? . Fo
(2) As a condition of the sale of a product to the government, a company, or a national of a country,
to refrain from shipping or insuring products on a carrier owned, leased or operated a a person
who does not participate in or cooperate with an international boycott? . .

12 (b) Requests and agreements.—if the answer to any part of 12(a) is “Yes,” indicate below: the country, the taxpayer iden-
tifying number, principal business activity code, description of the principal business activity, and the number and the
number code indicating the type of participation or cooperation requested or agreed to. (See Instructions.) If necessary,
attach additional sheets using the exact format and check box . eee ee ee --o

fae Principal business activity Tune of cooperation or participation — of cooperation of participation
Name of country receiving’ the anes Aarecd
request or entering Code Description Number |Code| Number | Code
into the agreement
(29) (2) @) (Oy (5) (6) @ (@)

(a)

(b)

(©)

(d)

(e)

(fy

(s)

(h)

@

@

(k)

0}

(m)

(1)

(0)

(p)

Je US. GOVERNMENT PRINTING OFFICE: 1977—-0-218-251 218-251-1


International Boycott Report
For taxable year beginning ...

To be Filed
in Duplicate

rom DU13

(May 1977)

Department of the Treasury and ending ... .
Internal Revenue Service > Controlled groups, see specific instruc ions. (See Instruction B)
Name ‘Taxpayer identifying number

Number and Street

City or town, State and ZIP code

Address of Service Center where your tax return is filed

Type of person filing this form (check one):
(Individual CO Partnership (J Corporation 7 Trust ( Estate C Other

1 _If an individual, enter adjusted gross income from your tax return (see instructions) .

2 Partnerships and corporations:
(a) If a partnership.—Enter the name and taxpayer identifying number of each partner.
(b) If a corporation.—Enter the name and employer identification number of all members of the controlled group (as defined in
section 993(a)(3)). If a consolidated return was filed, do not list members included in the consolidated return; instead, at-
tach a copy of Form 851. List all other members of the controlled group not included in the consolidated return.

Name ‘Taxpayer identifying
number

If necessary, attach additional sheets and checkbox. . . 2 6. ee ee ee ee --o

Code Description

(c) Enter principal business activity code and description (see instructions). .
(d) DISCs.—Enter principal product or service code and description (see instructions) .

3 Partnerships.—The following information must be submitted by each partnership filing Form 5713:

(a) Enter total assets of the partnership (Form 1065, page 1, itemC). . ......
(b)_Enter ordinary income of the partnership (Form 1065, line 26)... . . . . .

4 Corporations.—The following information must be submitted by every corporation filing Form S713:
(a) Type of form filed (Form 1120, 1120F, 11201, 1120M, etc.) . . . ...... |

(b) Common parent election (see instructions) —
(1) Name of common parent >.
(2) Employer identification number of common parent. . ........./1
(3) Taxable year of common parent beginning

(c) Corporations filing this form enter—

(1) Total assets (see instructions). . . . . . © . . .
(2) Taxable income before net operating loss and special deductions (see instructions) .

5 Estate or trust.—Enter total income (Form 1041, line 9). . . . .

Under penalties of perjury, 1 declare that | have examined this report, including accompanying schedules and statements, and to the best of my knowledge and belief it is true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.

Date - ‘Signature Bate

Titie Preparers address
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Form 5713 (5-77) Page 2

6 The following information must be submitted by every person filing Form 5713 (see specific instructions): Yes | No |
(a) Are you a United States shareholder (as defined in section 951(b)) of any foreign corporation that had reportable
operations under section 999(a)?. 2. 1 1 ew ew ew we ee ee - L re en
(b) If the answer to (a) is “Yes,” is any foreign corporation a controlled foreign ‘corporation (as defined i in section
957(a))? ee ee LL
(c) Do you own any stock of a DISC?. 2 2 ww ee ee fe
(d) Do you claim any foreign tax credit?. . . . 1. . 2. woe |__|
(e) Do you control (within the meaning of section 304(c)) any corporation (other ‘than a 2 corporation included | in this
report) that has reportable operations under section 999(a)?. . . . . foe rn ae
If “Yes,” did the corporation controlled by you participate in or cooperate with an international boycott at any
time during its taxable year that ends with or within your taxable year? . . . . es a ee
(f) Are you controlled (within the meaning of section 304(c)) by any person (other than : a person included in this
report) that has reportable operations under section 999(a)?. . . . . . oe
If “Yes,”” did the person controlling you participate in or cooperate with an international boycott at any time
during its taxable year that ends with or within your taxable year? . . . . .
(g) Are you treated under section 671 as the owner of a trust that has reportable operations under s section 1 999(a) -
(h) Are you a partner in a partnership that has reportable operations under section 999(a)?_ . . . 2. ww
MLZGM ~“Operations in or Related to a Boycotting Country (See Instructions)

7 Boycott of Israel.—Did you have any operations in or related to any country (or with the government, a company ora | Yes | No
national of such country) associated in carrying out the boycott of Israel which is on the list maintained by the Secre: [~~ |
tary of the Treasury under section 999(a)(3) (see Instruction C)?. . . Se ee

If “Yes,” enter name of the country(ies), taxpayer identifying number of person(s) having operations, principal busi-

ness activity code, and a description of the principal business activity. If necessary, attach additional sheets using the

exact format and check box... ee ee ee ee
Principal business activity

Taxpayer identifying number of
Name of country
person(s) having operations Code Description

@ (2) @) @

(a)

(b)

(c)

(d)

(e)

(fy)

(e)

(h)

@

@

()

O

(m)

(n)

(0)

218-251-1


Form 5713 (5-77) Page 3

8 Non-listed countries boycotting Israel—Did you have operations in any non-listed country which you know or have | Yes |_No_
reason to know requires participation in or cooperation with an international boycott directed against Israel? .
If “Yes,” enter the country(ies), taxpayer identifying number of person(s) having operations, the principal business
activity code, and a description of the Principal business activity. If necessary, attach additional sheets using
the exact format and check box . . . et sone el

Principal business activity

ing number of
1g operations Code Description

qa (2) (3) @)

Name of country Taxpayer (igen

(a)
(b)
(c)
(a)
(e)
0)
(e)
(bh)
10}
@
(k)
w
(m)
(ny
(0)
9 Boycotts other than the boycott of Israel—Did you have operations in any other country which you know or have |_Yes_|_No_
reason to know requires participation in or cooperation with an international boycott other than the boycott of Israel? .
If “Yes,” enter the country(ies), taxpayer identifying number of person(s) having operations, the principal business
activity code, and a description of the Principal business activity. If necessary, attach additional sheets using the
exact format and check box . . |
Principal business activity

Taxpayer identifying number of

Name of count
y person(s) having operations Code Description

a (2) 3) 4)

(a)
(b)
(c)
(a)
(e)
0)
()
(hy
10}

10}

(ky

0)

(m)
(ny
(0)

Yes | No

10 Were you requested to participate in or cooperate with an international boycott?. . . . . . .
If “Yes,” attach a copy (in English) of any and all such requests received during your taxable year. If the request v was
in a form other than a written request, attach a separate sheet explaining the nature and form of any and all such
requests. (See Instructions.)

11 Did you, in fact, participate in or cooperate with an international boycott? .

If “Yes,” attach a copy (in English) of any and all boycott clauses agreed to, and attach a general statement of the agreement.
If the agreement was in a form other than a written agreement, attach a separate sheet explaining the nature and form of any
and all such agreements. (See Instructions.)

Note: If the answers to questions 10 and 11 are “‘No,” you must file this form, but you do not have to complete Part Il; nor must you
file Schedules A, B, or C (Form 5713).

AN

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