Form 5471

(Rev. December 2011)

Department of the Treasury 

Internal Revenue Service

Information Return of U.S. Persons With Respect 

 To Certain Foreign Corporations

▶ See separate instructions.

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

section 898) (see instructions) beginning , 20 , and ending , 20

OMB No. 1545-0704

Attachment 

Sequence No. 121

Name of person filing this return

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

City or town, state, and ZIP code

 A Identifying number

B Category of filer (See instructions. Check applicable box(es)):

1 (repealed) 2 3 4 5

C Enter the total percentage of the foreign corporation’s voting 

stock you owned at the end of its annual accounting period %

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

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

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

Shareholder Officer Director

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(1) Employer identification number, if any

 b(2) Reference ID number (see instructions)

 c Country under whose laws incorporated

d Date of incorporation e Principal place of business f Principal business activity

code number

g Principal business activity h Functional currency

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

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

United States

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

(i) Taxable income or (loss) (ii) U.S. income tax paid 

(after all credits)

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

of incorporation

d 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

Schedule A Stock of the Foreign Corporation

(b) Number of shares issued and outstanding

(a) Description of each class of stock (i) Beginning of annual 

accounting period

(ii) End of annual 

accounting period

For Paperwork Reduction Act Notice, see instructions. Cat. No. 49958V Form 5471 (Rev. 12-2011)
Form 5471 (Rev. 12-2011) Page 2 

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

(a) Name, address, and identifying

number of shareholder

(b) Description of each class of stock held by

shareholder. Note: This description should

 match the corresponding description entered in 

Schedule A, column (a).

(c) Number of 

shares held at

beginning of annual

accounting period

(d) Number of 

shares held at 

end of annual

accounting period

(e) Pro rata share 

of subpart F 

income (enter as a 

percentage)

Schedule C Income Statement (see instructions)

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

Functional Currency U.S. Dollars

1a Gross receipts or sales . . . . . . . . . . . . . . . . . . . 1a 

b Returns and allowances . . . . . . . . . . . . . . . . . . . 1b

c Subtract line 1b from line 1a . . . . . . . . . . . . . . . . . 1c 

2 Cost of goods sold . . . . . . . . . . . . . . . . . . . . 2 

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

4 Dividends. . . . . . . . . . . . . . . . . . . . . . . . 4 

5 Interest . . . . . . . . . . . . . . . . . . . . . . . . 5 

6 a Gross rents . . . . . . . . . . . . . . . . . . . . . . . 6a 

b Gross royalties and license fees . . . . . . . . . . . . . . . . 6b

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 

Deductions

10 Compensation not deducted elsewhere . . . . . . . . . . . . . 10 

11a Rents . . . . . . . . . . . . . . . . . . . . . . . . . 11a

b Royalties and license fees . . . . . . . . . . . . . . . . . . 11b

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 

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 

Net Income

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 

21 Current year net income or (loss) per books (combine lines 18 through 20) . . . 21 

Form 5471 (Rev. 12-2011)
Form 5471 (Rev. 12-2011) Page 3 

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

Amount of tax

(a)

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

In foreign currency

(c) 

Conversion rate

(d) 

In U.S. dollars

1 U.S.

2 

3 

4 

5 

6 

7 

8 Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Schedule F Balance Sheet

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

for an exception for DASTM corporations.

Assets

(a) 

Beginning of annual

accounting period

(b) 

End of annual 

accounting period

1 Cash . . . . . . . . . . . . . . . . . . . . . . . . . 1 

2 a Trade notes and accounts receivable . . . . . . . . . . . . . . . 2a 

b Less allowance for bad debts . . . . . . . . . . . . . . . . . 2b ( ) ( )

3 Inventories . . . . . . . . . . . . . . . . . . . . . . . 3 

4 Other current assets (attach schedule) . . . . . . . . . . . . . . 4 

5 Loans to shareholders and other related persons . . . . . . . . . . . 5 

6 Investment in subsidiaries (attach schedule) . . . . . . . . . . . . 6 

7 Other investments (attach schedule) . . . . . . . . . . . . . . . 7 

8 a Buildings and other depreciable assets . . . . . . . . . . . . . . 8a 

b Less accumulated depreciation . . . . . . . . . . . . . . . . 8b ( ) ( )

9 a Depletable assets . . . . . . . . . . . . . . . . . . . . . 9a 

b Less accumulated depletion . . . . . . . . . . . . . . . . . . 9b ( ) ( )

10 Land (net of any amortization) . . . . . . . . . . . . . . . . . 10 

11 Intangible assets:

a Goodwill . . . . . . . . . . . . . . . . . . . . . . . . 11a

b Organization costs . . . . . . . . . . . . . . . . . . . . . 11b

c Patents, trademarks, and other intangible assets . . . . . . . . . . . 11c

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

12 Other assets (attach schedule) . . . . . . . . . . . . . . . . . 12 

13 Total assets . . . . . . . . . . . . . . . . . . . . . . . 13 

Liabilities and Shareholders’ Equity

14 Accounts payable . . . . . . . . . . . . . . . . . . . . . 14 

15 Other current liabilities (attach schedule) . . . . . . . . . . . . . . 15 

16 Loans from shareholders and other related persons . . . . . . . . . . . 16 

17 Other liabilities (attach schedule) . . . . . . . . . . . . . . . . 17 

18 Capital stock:

a Preferred stock . . . . . . . . . . . . . . . . . . . . . . 18a

b Common stock . . . . . . . . . . . . . . . . . . . . . . 18b

19 Paid-in or capital surplus (attach reconciliation) . . . . . . . . . . . 19 

20 Retained earnings . . . . . . . . . . . . . . . . . . . . . 20 

21 Less cost of treasury stock . . . . . . . . . . . . . . . . . . 21 ( ) ( )

22 Total liabilities and shareholders’ equity . . . . . . . . . . . . . . . . 22 

Form 5471 (Rev. 12-2011)
Form 5471 (Rev. 12-2011) Page 4 

Schedule G Other Information

 Yes No

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

partnership? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

3 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 (see instructions)? . . . . . . . . .

If “Yes,” you are generally required to attach Form 8858 for each entity (see instructions).

4 During the tax year, was the foreign corporation a participant in any cost sharing arrangement? . . . . . . . .

5 During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?

Schedule H Current Earnings and Profits (see instructions)

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

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

2 Net adjustments made to line 1 to determine current earnings and 

profits according to U.S. financial and tax accounting standards 

(see instructions):

Net 

 Additions

Net 

Subtractions

a Capital gains or losses . . . . . . . . . . . . . .

b Depreciation and amortization . . . . . . . . . . . .

c Depletion . . . . . . . . . . . . . . . . . . .

d Investment or incentive allowance . . . . . . . . . . .

e Charges to statutory reserves . . . . . . . . . . . .

f Inventory adjustments . . . . . . . . . . . . . . .

g Taxes . . . . . . . . . . . . . . . . . . . .

h Other (attach schedule) . . . . . . . . . . . . . .

3 Total net additions . . . . . . . . . . . . . . . .

4 Total net subtractions . . . . . . . . . . . . . . . . . . . . .

5 a Current earnings and profits (line 1 plus line 3 minus line 4) . . . . . . . . . . . . . . 5a 

b DASTM gain or (loss) for foreign corporations that use DASTM (see instructions) . . . . . . . 5b

c Combine lines 5a and 5b . . . . . . . . . . . . . . . . . . . . . . . . . . 5c 

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)) . . . . . . . . . . 5d

Enter exchange rate used for line 5d ▶

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

1 Subpart F income (line 38b, 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 

5 Factoring income . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

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

7 Dividends received (translated at spot rate on payment date under section 989(b)(1)) . . . . . . 7 

8 Exchange gain or (loss) on a distribution of previously taxed income . . . . . . . . . . . 8 

 Yes No

• Was any income of the foreign corporation blocked? . . . . . . . . . . . . . . . . . . . . . . .

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

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

Form 5471 (Rev. 12-2011)