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

Respect To Certain Foreign Corporations Form 5471

(Rev. January 2003)

File In Duplicate

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

section 898) (see instructions) beginning , 20 , and ending , 20 Department of the Treasury

Internal Revenue Service

Name of person filing this return A Identifying number

Category of filer (See page 1 of the instructions. 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

12345

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

you owned at the end of its annual accounting period %

C

Filer’s tax year beginning , 20 , and ending , 20

Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be stated

in U.S. dollars unless otherwise indicated.

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, enter:

(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 13 of the instructions. Form 5471 (Rev. 1-2003)

 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 on page 1 of

the instructions)

h Functional currency
Form 5471 (Rev. 1-2003) Page 2

U.S. Shareholders of Foreign Corporation (See page 4 of the 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: Report all information in functional currency in accordance with U.S. GAAP. Also, report each amount in

U.S. dollars translated from functional currency (using GAAP translation rules). However, if the functional

currency is the U.S. dollar, complete only the U.S. Dollars column. See instructions for special rules for

DASTM corporations.

Income Statement (See page 5 of the instructions.)

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 (combine lines 18 through 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. 1-2003)
Form 5471 (Rev. 1-2003) Page 3

Income, War Profits, and Excess Profits Taxes Paid or Accrued (See page 5 of 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 shareholders 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 Shareholders’ Equity

16

Accounts payable

17

Other current liabilities (attach schedule)

18a

Loans from shareholders 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 shareholders’ equity

2b

18b

16

17

18

19

20

21

22

(c)

Conversion rate

Schedule E

Schedule F

5

6

7

Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See page 5 of

the instructions for an exception for DASTM corporations.

Form 5471 (Rev. 1-2003)
Form 5471 (Rev. 1-2003) Page 4

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 page 5 of 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 Total of lines 1 through 5. Enter here and on your income tax return. See page 6 of instructions 6

● Was any income of the foreign corporation blocked?

Factoring income

Taxes

h

Schedule H

Schedule I

If the answer to either question is “Yes,” attach an explanation.

5a 5a

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

defined in section 989(b) and the related regulations (see instructions))

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

Current Earnings and Profits (See page 5 of the instructions.)

Yes No

● Did any such income become unblocked during the tax year (see section 964(b))?

Important: Enter the amounts on lines 1 through 5c in functional currency.

Schedule G Other Information

During the tax year, did the foreign corporation own at least a 10% interest, directly or indirectly, in any foreign

partnership?

Yes No

During the tax year, did the foreign corporation own an interest in any trust?

During the tax year, did the foreign corporation own any foreign entities that were disregarded as entities separate

from their owners under Regulations sections 301.7701-2 and 301.7701-3?

If “Yes,” attach a statement listing the name, country under whose laws the entity was organized, and EIN (if any)

of each entity.

If “Yes,” see page 5 of the instructions for required attachment.

1

2

3

Form 5471 (Rev. 1-2003)