Form 5452
(Rev. Nov. 1981)

Department of the Treasury
Internal Revenue Service

Corporate Report of Nontaxable Dividends

For calendar year ending December 31, 1

OMB No. 1545-0205
Expires 9-30-84

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

Paperwork Reduction Act Notice.—The Paperwork Reduction
Act of 1980 says we must tell you why we are collecting this in-
formation, how we will use it, and whether you have to give it
to us. We ask for the information to carry out the Internal Rev-
enue laws of the United States. We need it to ensure that you
are complying with these laws and to allow us to figure and col-
lect the right amount of tax. You are required to give us this
information.

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
by February 28 following the close of. the calendar year, with the
Director, Corporation Tax Division, T:C:C:1:1, Internal Revenue
Service, Washington, D.C. 20224. Note: File earnings and profits
computations for section 333 liquidations with your Form 1120.

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 tax 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 shareholders that are corporations and those that
are not (individuals, partnerships, etc.), show the number of
shares held by and the amounts paid to each.

5. Specific data.—The earnings and profits of the tax year
beginning ... were §.... -_

This is an estimate [7] or the actual amount [_], based on U.S.
Corporation Income Tax Return, Form 1120.

The number of shareholders of record on the date of the last
dividend payment was:

© Corporations ..
© Individuals, partnerships, et

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

$

6. Supporting data—(a) If you filed Form 1120, attach the
following to this form: (1) a computation of earnings and profits
of the tax year,* and a schedule of differences between Sched-
ule M and these earnings and profits; (2) a year-by-year compu-
tation of accumulated earnings and profits, and a schedule of
differences since the origin of the company, February 28, 1913,
or the last year for which such data was previously furnished,
whichever is later; (3) a copy of Schedules M-1 and M-2 (with
any supporting schedules); and (4) an ending book (Schedule L,
Form 1120) vs. tax-basis balance sheet. If you use accelerated
depreciation, attach a schedule summarizing the depreciation
(and any amortization) computed under the straight-line method
and a reconciliation of any difference between that amount and
the amount claimed on Form 1120. (For examples, see Exhibits
in Rev. Proc. 75-17, 1975-1 CB, 677.)

(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.—If 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 [] 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
i ‘Amount paid during year from earnings and || Amount paid during year from other than earn-
. Total amount paid Amount per , a
Date paid (Common (C) Preferred (P)) share” || Profits of the current year or accumulated since || ings, and, profits of the current year or ac

February 28, 1

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Totals _|$

Date ... --- Signature _..



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