rom S452

(Rev. August 1989)

Department of the Treasury
Internal Revenue Service

Corporate Report of Nondividend Distributions

For calendar year ending December 31,19 __

OMB No. 1545-0205
Expires 7-31-92

Name as shown on return

Employer identification number

Number and street (or P.O. box number if mail is not delivered to street address)

Date incorporated

City or town, state, and ZIP code

Tax year ending (month, day, year)

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

Telephone number

¢ )

Type of entity:
0 Corporation
oOo Foreign Corporation

C1 Insurance Company 1 Other (Specify)

(see instructions)

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

Method of accounting: | [1] Check here if a Form 5452 has
oO been filed for a prior year. (Attach
Cash copy of determination letter.)
CO Accrual [1 Check here if any of these

distributions are part of a
complete or partial liquidation.
(Describe in detail.)

C1 Other (Specify)

If you believe that nondividend distributions have been made
during the calendar year shown above, and would like an
extension of time to file the supporting data required by item
6 of the instructions, we will grant an extension provided:

Request (1) you have not filed your tax return for the year, and
extension (2) you have not advised your shareholders that they have
oftime _“eceived nondividend distributions, and
to file (3) you are not requesting an extension beyond 9 months

Form 5452 ‘tom the due date for filing your return (without extensions).
extension requested to
Coext ted t
‘(Enter date)

Note: /f you do not furnish the supporting data by the extension date
requested above, the distributions listed in Column 1 below will continue to
be fully taxable to your shareholders.

Earnings and profits information:

@ Accumulated E & P (since 2-28-13) at beginning of
tax year $

@ Actual E & P of the current tax year $

Classification of shareholders at date of last dividend payment:
@ Number of individuals

@ Number of partnerships __

@ Number of corporations and other shareholders

Note: /f you have 12 or fewer shareholders, attach copies of the Forms
1099-DiV (or the information from that form) that you gave to shareholders.

Column 1 Column 2 Column 3
7 ry n 1 “Amount paid di Tend
Date paid (on! amen il, ey | Amount per |[_ Amount pa during calendar year fom earings and profs since February 28,1913 | percent || eortorameticgcoanes | Percent
Other (0)) share From the current year ‘Accumulated Total taxable || and Droits se February 28, nontaxable
$ $ $ $ $ $
Totals | $ $ $ $ $ Uff

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

correct, and complete.

Signature of Corporate Officer

Instructions
(Section references are to the Internal Revenue Code unless otherwise noted.)
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 this information.

The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is:

Recordkeeping . . . . 21 hrs., 46 min.
Learning about

thelawortheform. . . 2... we Lhr., 8 min.
Preparingtheform. . . . . . . 3hrs., 24 min.
Copying, assembling, and

sendingtheformtoIRS .. ...... . . «32min.

If you have comments concerning the accuracy of these time
estimates or suggestions for making this form more simple, we
would be happy to hear from you. You can write to either the
Internal Revenue Service, Washington, DC 20224, Attention: IRS
Reports Clearance Officer, T:FP; or the Office of Management
and Budget, Paperwork Reduction Project (1545-0205),
Washington, DC 20503.

1. Who Must File. —File Form 5452 if you make nondividend
distributions under sections 301 or 1368(c)(3) of the Internal
Revenue Code to your shareholders. If you are a member of a

consolidated group, an officer of the parent corporation must sign
Form 5452. An S corporation should file this form and check
“Other” under “Type of entity” only with respect to distributions
made under section 1368(c)(3).

2. When and Where To File. —File Form 5452 by
February 28 following the close of the calendar year, with the
Assistant Chief Counsel (Income Tax and Accounting),

P.O. Box 7604, Ben Franklin Station, Washington, DC 20044.

3. Nondividend Distributions.—These are distributions made
to shareholders in the normal course of business. They are
considered fully or partially nontaxable as dividends only because
the paying corporation's current and accumulated earnings and
profits are less than the distributions. Nondividend distributions do
not include tax-free stock dividends or distributions exchanged for
stock in liquidations or redemptions.

4. Calendar Year Basis.—Report all distributions made 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 fully taxable
until a determination can be made on the taxability of the
distributions based on the following tax years’ current and
accumulated earnings and profits. See Regulations section
1.6042-3(c).

5. Taxable Status Reported to Shareholders. —Complete the
table above showing the taxable and nontaxable status of
distributions reported to shareholders. If noncash distributions
were made, show their tax bases and fair market values.

Form 5452 (Rev. 8-89)


Form 5452 (Rev. 8-89)

Page 2

6. Supporting Data.—(a) Attach the following to this form:
(1) a computation of earnings and profits of the tax year (see
illustration below and the worksheet on page 3 that you may want
to use in making your computation of earnings and profits), anda
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 nondividend distributions,
the data described above in item 6(a) on the basis of each
member's taxable income or loss.

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

Anycity, Yourstate 20200
Icrported 1/1/74 a ae
Accrual Method of Accounting Dar Tel Dat can | Cm Blane
12/31/88 Balance forward $225,000 $20,900
1989
Taxable income from line 28, page 1, Form 1120 . 214,700 $214,700 v
Federal income taxes shown in books . $89,556 a
Federal income taxes shown on tax return $89,556 a
Excess of capital losses over capital gains (tax basis) . 3,600 3,600 v
Section 312(k) depreciation adjustment . . 24,000
Depreciation adjustment on property disposition 4,000
Contributions in excess of limitation . . $200 200 Vv
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 . 500 500 Vv
Total itemized expenses from line 5, Schedule M- 1 11,050
Life insurance proceeds in excess of CSV 6,000 6,000 v
Bad debt recovery (not charged against taxable income) 3,500 1-1985
Tax-exempt interest on municipal bonds . . [5,000 5,000 v
Total itemized income from line 7, Schedule M-1. 14,500
Refund of prior year Federal income taxes. 18,000 1-1986
Reserve for contingencies 4 10,000
108,206 | 249,700
Current-Year Earnings and Profits 141,494
Cash Distributions:
Preferred: 3/15, 6/15, 9/15, 12/15/89 20,000. 20,000 Vv
$0.50/Sh-10,000 Shs
Common: —_ 3/31/89 __
$1.00/Sh-90,000 Shs %
From current-year earnings and profits . . . xx 60,747 60,747 v
From accumulated earnings and profits . . .__*% 20,900 (20,900)|
90.72% | 81,647
From Other . . . 9.28% | 8,353
Totaldistribution . . . . . 100_% | 90,000
9/30/89
$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-year change. 67,006 (20,900)
Balance forward 12/31/89 | $157,994 $—0—

NOTE: For explanation of key, see Rev. Proo. 75: V7, 1975 1C.B. 677.


Form 5452 (Rev. 8-89)

Page 3

Worksheet for Computing Current-Year Earnings and Profits

Incorporated _
Method of Accounting

Retained Earnings
‘Shown in Books

Earnings and Profits
Current Year

Debit Credit

Debit Credit

‘Accumulated
Credit Balance

Key

12/31/ _ Balance forward

Taxable income from line 28, page 1, Form 1120 .
Federal income taxes shown inbooks. . . .
Federal income taxes shown ontaxreturn . . .
Excess of capital losses over capital gains (tax basis) .
Section 312(k) depreciation adjustment. . . . . .
Depreciation adjustment on property disposition . . .
Contributions in excess of limitation . .
Life insurance premium in excess of cash surrender value (sv)
Nondeductible interest paid to carry tax-exempt bonds .
Unallowed contributions. . . .
Other(list) © 6. 2 ee ee
Total itemized expenses from line 5, Schedule M- 1
Life insurance proceeds in excess of CSV
Bad debt recovery (not charged against taxable income)
Tax-exempt interest on municipal bonds. . .
Other(list) . 2 2. oe .
Total itemized income from ine 7, Schedule Me 1.
Refund of prior year Federal incometaxes . . . .
Reserve forcontingencies . . 2... 2. wwe
Additional Adjustments:

Current-Year Earnings and Profits
Cash Distributions:

%
From current-year earnings and profits . .
From accumulated earnings and profits . .
%
Fromother . . . 1. ee ee ee
Total distribution . . . . . . . . ,400_%

Totalcash distributions . . . 2 1 1 ee ee

Current-yearchange . . 2... 1 we
Balance forward 12/31,