rorm 5452

(January 1976)
(Replaces Sch, A(Form 1096))

Department of the Treasury
Internal Revenue Service

Corporate Report of Nontaxable Dividends

For calendar year ending December 31, 19.

Name as shown on Form 1120

Employer identification number

Address (number and street)

Date incorporated

City, State, and ZIP code

Telephone number (including area code)

Specific Instructions

1. When and where to file—You should complete and file
Form 5452 if you pay nontaxable dividends to your share-
holders and if you are not a subchapter S corporation making
actual distributions from income previously taxed. File this form
on or before February 28 following the close of the calendar year,
with the Director, Corporation Tax Division, T:C:C:3:E&P, Internal
Revenue Service, Washington, D.C. 20224.

2. Nontaxable dividends.—For purposes of this return, non-
taxable dividends are distributions paid to shareholders in the
normal course of business. They are considered wholly or par-
tially nontaxable as dividends only because the paying corpora-
tion’s current and accumulated earnings and profits are less than
the distributions. Nontaxable dividends do not include tax-free
stock dividends or distributions exchanged for stock in liquida-
tions or redemptions.

3. Calendar year basis.—If you paid nontaxable dividends to
shareholders, report all dividends paid during the calendar year,
even if you use a fiscal year as your taxable year and have not
yet filed Form 1120.

4. Taxable status reported to shareholders.—Please complete
the table below showing the taxable status of distributions re-
ported to shareholders. If non-cash distributions were made,
show their tax bases and fair market values. Also, if distributions
were made to both corporate and noncorporate shareholders,
show the number of shares held by and the amounts paid to
each.

5. Specific data——The earnings and profits of the taxable

year beginning were $
This 1s an estimate [-] or the actual amount [-], based on U.S.
Corporation Income Tax Return, Form 1120.

The number of shareholders of record on date of last dividend
.. for corporate,
. “for noncorporate.

At the beginning of the taxable year, the balance of earn-
ings and profits accumulated after February 28, 1913 was

$.

payment was

6. Supporting data.—(a) If you filed Form 1120, attach to this
form a computation of earnings and profits of the taxable yeal
and a schedule of differences between Schedule M and such
earnings and profits; a year-by-year computation of accumulated
earnings and profits, and a schedule of differences since origin
of the company, February 28, 1913, or the last year for which
such data was previously furnished, whichever is later; a copy of
Schedules M-1 and M-2 (with any supporting schedules); and an
ending book (Schedule L, Form 1120) vs. tax-basis balance
sheet; and if you use accelerated depreciation, a schedule sum-
marizing the depreciation (and any amortization) computed
under the straight-line method and a reconciliation of any
difference between such amount and the amount claimed on
Form 1120. (For examples, see Exhibits in Rev. Proc. 75-17,
1975-13, I.R.B. 20.)

(b) If you filed a consolidated return, Form 1120, attach the
following in addition to the items described above: (1) a schedule
showing the allocation of the consolidated tax liability and the
method used (if an intercompany agreement is in effect, give
complete details); (2) a schedule showing the separate taxable
income or loss for each member-company included in the con-
solidated return; and (3) for each member-company paying non-
taxable dividends, the data described above in paragraph 6(a)
on the basis of the member-company’s taxable income or loss.

7. Extension.—lf you have not filed Form 1120, and you
need an extension to file supporting data described in instruction
6 above, we will grant an extension of time until the due date of
your return if you complete the following:

Extension requested [1] to - (date).
Note: If you do not furnish the supporting data required

above, IRS may assume you have redetermined your distribu-
tions to your shareholders to be fully taxable as dividends.

*See illustration on the back.

Column 1 ]

Column 2 Column 3

Total amount paid

Date paid (Common (C) Preferred (P)) share

‘Amount per || Amount paid during year from earnings and || Amount paid during year from other than earn-
Per |) profits of the current year or accumulated since || ings and profits of the current year or ac-
February 28, 1913 5

cumulated since February 28,

$ ade $ _.|$.

i$

Wilda

aA

Totals $

Date...

16—82690-1


Illustration of a Current-Year Earnings and Profits Computation

XYZ Corporation, E. 1. No. 00-0000000
123 Main Street
Anycity, Yourstate 20200

Retained Earnings Earnings and Profits
Incorporated 1/1/54 Shown in Books Current Year Accumulated Key
Accrual Method of Accounting Debit credit Debit credit Credit Balance
12/31/74 Balance forward _| $225,000 |. $20,900
1975 ~

Taxable income from line 28, page lofreturn . . 2. 2 2 1. + ee 7 214,700 $214,700 Vv
Federal income taxes shown in books a : a
Federal income taxes shown on tax return : _ $89 556 a
Excess of capital losses over capital gains (tax basis) : 3,600 Vv
Section 312(m) depreciation adjustment fone
Depreciation adjustment on property disposition . . . - . 1. 4,000

Contributions in excess of limitation . a $200 200 Vv

Life insurance premium in excess of cash surrender value (CSV). 9,500 9,500 Vv

Non-deductible interest paid to carry tax-exempt bonds . . . . 850 850 Vv

Unallowed contributions . . Fo ee 500 500 Vv

Total itemized from line 5, Schedule M-1 soe 11,050

Life insurance proceeds in excess of CSV... . soe 6,000 Vv

Bad debt recovery (not charged against taxable income) hoe 3,500 1-1973

Tax-exempt interest on municipal bonds... . 7 ew ee 5,000 Vv

Total itemized from line 7, Schedule M-1
Refund of 1971 Federal income taxes Coe ee 18,000 1-1974
Premium paid on redemption of preferred stock 1... 25,000
Reserve for contingencies . 2... 2. ee ee ee ee 10,000 i
; 108,206 249,700
Current-Year Earnings and Profits ———_____ | 441,494 |

Cash Distributions:

Preferred: 3/15, 6/15, 9/15, 12/15/75 20,000 Vv

$0.50/Sh—10,000 Shs
Common: 3/31/75
$1.00/Sh—90,000 Shs %
From current-year earnings and profits Xxx 60,747 _ Vv
From accumulated earnings and profits XX (20,900) Vv
90.72%

From Other 9.28

Total distribution 100%

9/30/75
$1.00/Sh—90,000 Shs

From current-year earnings and profits 67.50% 60,747 |_ 60,747 Jov
From Other 32.50

Total distribution 100%
Total cash distributions x

339,206 247,200 141,494 141,494

Currentyear change. 2 1 / ee 92,006 (20,900)
Balance forward 12/31/75 wt i “pF

NOTE: For Explanation of Key, See Rev. Proc. 75-17, 1975-13, |.R.B. 20 U.S. G.P.0. 1976-626-367/1009 — 16~-82090-1