rom DAO

(Rev. June 1987)
Department of the Treasury
Internal Revenue Service

Corporate Report of Nontaxable Dividends

For calendar year ending December 31, 19...

OMB No. 1545-0205,
Expires 5-31-90

Name as shown on return

Employer Identification number

Number and street

Date incorporated

City, state, and ZIP code

Tax year ending (month, day, year)

Name of person to contact (if representative, attach power of attorney)

Type of entity:

© Corporation
O Foreign Corporation

CO Insurance Company Oo Other (Specify)

C1 Regulated Investment Co. (RIC)
CO Real Estate Investment Trust (REIT)

Telephone number
¢ )
Method of accounting: | [7] Check here if a Form 5452 has
gO been filed for a prior year. (Attach
Cash copy of determination letter.)
0 Accrual (1 Check here if this is a section 333

liquidation. (File this form and the
earnings and profits computation
with your income tax return.)

0 Other (Specify)

1_S Corporation (No. of shareholders ) ——
i h ¢ filed tax return for th Earnings and profits information:
jou have not filed your tax return for the year ,
shown above and you need an extension of time to | @ Accumulated E & P (since 2-28-13) at beginning of tax year $
Request file the supporting data requested in item 5 below, @ E&Pofthecurrenttaxyear$___—
g we will grant an extension until the due date of your
for return (including extensions). (This is [] an estimate/[[] actual! amount based on tax return.)
extension Extension requested to Classification of shareholders at date of last dividend payment:
to file (Enter date) @ Number of individuals.
Note: If you do not furnish the supporting data, IRS
Form 5452 vi assume you have redetermined the ‘© Number of partnerships —_____
distributions to your shareholders to be fully taxable @ Number of corporations and other shareholders__-_=
as dividends. Note: If you have 12 or fewer shareholders, please attach copies of the Forms
1099-DIV (or the information shown on that form) that you gave to the shareholders.
Instructions distributions reported to shareholders. If noncash distributions

(Section references are to the Internal Revenue Code, unless
otherwise noted.)

1, When and Where to File.—File Form 5452 if you pay
nontaxable dividends to your shareholders. File by February 28
following the close of the calendar year, with the Director,
Corporation Tax Division, CC:C, Internal Revenue Service,
Washington, D.C. 20224 (but for a section 333 liquidation file this
form and your earnings and profits computation with your income tax
return). If you are a member of a consolidated group, an officer of
the parent corporation must sign Form 5452.

2. Nontaxable Dividends.—These are distributions paid to
shareholders in the normal course of business. They are considered
wholly or partially nontaxable as dividends only because the paying
corporation'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 liquidations or
redemptions.

3. Calendar Year Basis.—Report all dividends paid during the
calendar year, even if you use a fiscal year as your tax year and have
not yet filed your income tax return.

Distributions made after the fiscal year ends are deemed to be
fully taxable until a determination can be made based on the
following year’s tax return. See regulations section 1.6042-3(c).

4. Taxable Status Reported to Shareholders.—Complete the
table below showing the taxable and nontaxable status of

were made, show their tax bases and fair market values.

5. Supporting Data.—(a) Attach the following to this form:
(1) a computation of earnings and profits of the tax year (see
illustration on back), and a schedule of differences between
Schedule M and these earnings and profits; (2) a year-by-year
computation 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 pages 1 and 4 of Form
1120, or equivalent information from other corporate return (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 or equivalent form. (For
examples, see Exhibits in Rev. Proc. 75-17, 1975-1 C.B. 677.)

(b) If you file a consolidated return, attach the following in
addition to the items described above: (1) a schedule showing the
allocation of the consolidated tax liability and identifying 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 of the group filing a consolidated
return; and (3) for each member paying nontaxable dividends, the
data described above in item 5(a) on the basis of each member's
taxable income or loss.

Column 1 Column 2 Column 3
Total amount paid “Amount paid during year from earnings and profits since February 28, 1913 “Amount paid during year from
fy (Common (C) Preferred (P) | Amount per Percent 1 other than earnings and pris | Percent
ate pad « athe ° share From the current year ‘Accumulated Total taxable sina Febuary 22,1813. | nontaxable
$ $ $ $ $ $
Totals _|$ $ $ $ $

Under penalties of perjury, | declare that | have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief itis true,

correct, and complete.

Signature of Corporate Officer

Form 5452 (Rev. 6-87)


Illustration of a Current-Year Earnings and Profits Computation
XYZ Corporation, E. I. No. 00-0000000

123 Main Street
Anycity, Yourstate 20200
Retained Earnings Earnings and Profits
Incorporated 1/1/74 Shown in Books Current Year pecumulated mn
Accrual Method of Accounting petit credit petit creit Gredit Batance Y
12/31/84 Balance forward $225,000 $20,900
1985
Taxable income from line 28, page lofreturn . . . . 214,700 $214,700 v
Federal income taxes shown inbooks =. . . . . . $89,556 a
Federal income taxes shownontaxreturn . . . $89,556 a
Excess of capital losses over capital gains (tax basis) . 3,600 3,600 v
Section 312(k) depreciation adjustment Soe 24,000
Depreciation adjustment on property disposition . . . 4,000
Contributions in excess of limitation... $200 200 v
Life insurance premium in excess of cash surrender value (csv) 9,500 9,500 Vv
Nondeductible interest paid to carry tax-exempt bonds . 850 850 v
Unallowed contributions. to 500 500 v
Total itemized from line 5, Schedule M 1 hon 11,050
Life insurance proceeds inexcessofCSV . . . . 6,000 6,000 v
Bad debt recovery (not charged against taxable income). 3,500 1-1983
Tax-exempt interest on municipalbonds . . . . 5,000 5,000 v
Total itemized from line 7,ScheduleM-1 . . . 14,500
Refund of prior year Federalincometaxes . . . . . 18,000 1-1984
Reserve forcontingencies . . . ....... 10,000
108,206 | 249,700
Current-Year Earnings and Profits 141,494
Cash Distributions:
Preferred: 3/15, 6/15, 9/15, 12/15/85 20,000 20,000 Vv
$0.50/Sh-10,000 Shs
Common: —_ 3/31/85
$1.00/Sh-90,000 Shs %
From current-year earnings and profits xX 60,747 60,747 v
From accumulated earnings and profits x 20,900 (20,900)| v
90.72% | 81,647
From Other 9.28 8,353
Total distribution 100_% | 90,000
—— 9/30/85 __
$1.00/Sh-90,000 Shs
From current-year earnings and profits 67.50% 60,747 60,747 v
From Other 32.50 29,253
Total distribution 100_% | 90,000
Total cash distributions 200,000
314,206 | 247,200] 141,494 | 141,494
Current-yearchange . . 1 2 ew ee es 67,006 (20,900)
Balance forward 12/31/85 oe 157,994 $—0—

NOTE: For Explanation of Key, See Rev. Proc. 75-17, 1975-1 C.B. 677.

Paperwork Reduction Act Notice.— We ask for this information to carry out the Internal Revenue laws of the United States. We need it to
ensure that taxpayers are complying with these laws and to allow us to figure and collect the right amount of tax. You are required to give us
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U.S. Government Printing Office: 1987—181-447/60028