OMB No. 1545-0704 Information Return of U.S. Persons With

Respect To Certain Foreign Corporations Form 5471

(Rev. June 1995)

File In Duplicate

Information furnished for the foreign corporation’s annual accounting period (tax year required by

section 898) (see instructions) beginning ,19 , and ending ,19 Department of the Treasury

Internal Revenue Service

Name of person filing this return A Identifying number

Category of filer (see Who Must File in the instructions and check applicable

box(es)):

Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address) B

(1) (2) (3) (4) (5)

City or town, state, and ZIP code Enter the total percentage of voting stock of the foreign corporation

you owned at the end of its annual accounting period %

C

Filer’s tax year beginning , 19 , and ending , 19

Fill in all applicable lines and schedules. All information must be in the English language. All amounts

must be stated in U.S. dollars unless otherwise indicated.

Enter the foreign corporation’s functional currency ©

Important:

1a Name and address of foreign corporation b Employer identification number, if any

c Country under whose laws incorporated

Principal business activity g Principal business activity

code number

Date of incorporation e Principal place of business f

a

2 Provide the following information for the foreign corporation’s accounting period stated above.

b If a U.S. income tax return was filed, please show:

(ii) U.S. income tax paid

(after all credits)

Name, address, and identifying number of branch office or agent (if any) in

the United States

(i) Taxable income or (loss)

Name and address (including corporate department, if applicable) of

person (or persons) with custody of the books and records of the foreign

corporation, and the location of such books and records, if different

Name and address of foreign corporation’s statutory or resident agent in d

country of incorporation

c

Stock of the Foreign Corporation

Part I—ALL Classes of Stock

(b) Number of shares issued and outstanding

(ii) End of annual

accounting period

(i) Beginning of annual

accounting period

(a) Description of each class of stock

Part II—Additional Information for PREFERRED Stock

(To be completed only by Category (1) filers for foreign personal holding companies)

(d) Indicate whether the

stock is cumulative or

noncumulative

(a) Description of each class of PREFERRED stock

(Note: This description should match the corresponding

description entered in Part I, column (a).)

(c) Rate of dividend (b) Par value in

functional currency

For Paperwork Reduction Act Notice, see page 1 of the instructions. Form 5471 (Rev. 6-95)

© See separate instructions.

(4) Check applicable box(es) (1) Name (2) Address (3) Identifying number Shareholder Officer Director

D Person(s) on whose behalf this information return is filed:

Schedule A

Cat. No. 49958V

d

(see When and Where

To File in the

instructions)
Form 5471 (Rev. 6-95) Page 2

U.S. Shareholders of Foreign Corporation (see instructions)

(c) Number of

shares held at

beginning of

annual

accounting period

(d) Number of

shares held at

end of annual

accounting

period

(b) Description of each class of stock held by

shareholder (Note: This description should match the

corresponding description entered in Schedule A,

Part I, column (a).)

(a) Name, address, and identifying number of shareholder

Important: Schedule C requests financial accounting information prepared in functional currency in accordance with

U.S. GAAP. Each line must also be reported in U.S. dollars translated from functional currency in accordance

with U.S. GAAP translation rules. See instructions for special rules for DASTM corporations.

Income Statement (Complete both columns unless the functional currency is the U.S. dollar. In

that case, complete only the U.S. Dollars column.)

1a Gross receipts or sales 1a

2 Cost of goods sold 2

3 Gross profit (subtract line 2 from line 1c) 3

4 Dividends 4

Income

5 Interest 5

6 Gross rents, royalties, and license fees 6

7 Net gain or (loss) on sale of capital assets 7

8 Other income (attach schedule) 8

9 Total income (add lines 3 through 8) 9

10 Compensation not deducted elsewhere 10

11 Rents, royalties, and license fees 11

12 Interest 12

13 Depreciation not deducted elsewhere 13

14 Depletion 14

15 Taxes (exclude provision for income, war profits, and excess profits taxes) 15

Deductions

16

Other deductions (attach schedule—exclude provision for income, war profits,

and excess profits taxes)

16

17 Total deductions (add lines 10 through 16) 17

18 Net income or (loss) before extraordinary items, prior period adjustments, and

the provision for income, war profits, and excess profits taxes (subtract line

17 from line 9) 18

19 Extraordinary items and prior period adjustments (see instructions) 19

20 Provision for income, war profits, and excess profits taxes (see instructions) 20

Net Income

21 Current year net income or (loss) per books (line 18 plus line 19 minus line 20) 21

(e) Pro rata share

of subpart F

income (enter as

a percentage)

Schedule B

Schedule C

Functional Currency U.S. Dollars

Returns and allowances

Subtract line 1b from line 1a

b

c

1b

1c
Form 5471 (Rev. 6-95) Page 3

Income, War Profits, and Excess Profits Taxes Paid or Accrued (see instructions)

Amount of tax

(a)

Name of country or U.S. possession (d)

In U.S. dollars

(b)

In foreign currency

1 U.S.

2

3

4

8 Total ©

Balance Sheet

(b)

End of annual

accounting period

(a)

Beginning of annual

accounting period

Assets

1 Cash 1

2a Trade notes and accounts receivable 2a

( ) ( ) b Less allowance for bad debts

3 Inventories 3

4 4

5 5

6

Other current assets (attach schedule)

6

7

Loans to stockholders and other related persons

7

8a

Investment in subsidiaries (attach schedule)

8a

8b

Other investments (attach schedule)

9a 9a

Buildings and other depreciable assets

10

( )( )

9b

b Less accumulated depreciation

10

11

Depletable assets

( ) ( )

11a

b Less accumulated depletion

11b

12

Land (net of any amortization)

11c

13

Intangible assets:

a Goodwill

11d

b Organization costs

12

c Patents, trademarks, and other intangible assets

( )( )

13

d Less accumulated amortization for lines 11a, b, and c

14 14

Other assets (attach schedule)

Total assets

15 15

Liabilities and Stockholders’ Equity

16

Accounts payable

17

Other current liabilities (attach schedule)

18a

Loans from stockholders and other related persons

19

Other liabilities (attach schedule)

20

a Preferred stock

Capital stock:

b Common stock

21

Paid-in or capital surplus (attach reconciliation)

Retained earnings

22

( ) ( ) Less cost of treasury stock

Total liabilities and stockholders’ equity

2b

18b

16

17

18

19

20

21

22

(c)

Spot conversion rate

Schedule E

Schedule F

Does the foreign corporation have an interest in a partnership or trust? Yes No

5

6

7

Important: Schedule F requests financial accounting information prepared and translated into U.S. dollars in

accordance with U.S. GAAP. See instructions for exception for DASTM corporations.
Form 5471 (Rev. 6-95) Page 4

Current Earnings and Profits (enter the amounts on lines 1 through 5c in functional currency)

1 Current year net income or (loss) per foreign books of account 1

Net adjustments made to line 1 to determine current

earnings and profits according to U.S. financial and tax

accounting standards (see instructions):

2

Net

Subtractions

Net

Additions

a Capital gains or losses

b Depreciation and amortization

c Depletion

d Investment or incentive allowance

e Charges to statutory reserves

f Inventory adjustments

Other (attach schedule) 

g

3 Total net additions

4 Total net subtractions

Current earnings and profits (line 1 plus line 3 minus line 4)

5d

Summary of Shareholder’s Income From Foreign Corporation (see instructions)

1 Subpart F income (line 40b, Worksheet A in the instructions) 1

2 Earnings invested in U.S. property (line 17, Worksheet B in the instructions) 2

3 Previously excluded subpart F income withdrawn from qualified investments (line 6b, Worksheet C in

the instructions) 3

4 Previously excluded export trade income withdrawn from investment in export trade assets (line 7b,

Worksheet D in the instructions) 4

6 6

Total of lines 1 through 6. Enter here and on your income tax return 

9 9

Yes No

Was any income of the foreign corporation blocked OR did any become unblocked during the tax year (see section 964(b))?

Factoring income

Taxes

h

Schedule H

Schedule I

If the answer to either part of the question is “Yes,” check the “Yes” box and attach an explanation

5a 5a

d Current earnings and profits in U.S. dollars (line 5c translated at the weighted average exchange rate as

defined in Regulations Section 1.989(b)-1)

Enter exchange rate used for line 5d ©

Dividends received (translated at spot rate on payment date under section 989(b)(1))

Exchange gain or (loss) on a distribution of previously taxed income

7

8

7

8

c

b DASTM gain or (loss) for foreign corporations that use DASTM (see instructions)

Combine lines 5a and 5b

5b

5c

5 5 Earnings invested in excess passive assets (line 21, Worksheet E in the instructions)

Printed on recycled paper