Form 8621

(Rev. December 2012) 

Department of the Treasury 

Internal Revenue Service 

Information Return by a Shareholder of a Passive Foreign 

 Investment Company or Qualified Electing Fund 

▶ Information about Form 8621 and its separate instructions is at www.irs.gov/form8621.

OMB No. 1545-1002 

Attachment 

Sequence No. 69

Name of shareholder 

Number, street, and room or suite no. (If a P.O. box, see instructions.) 

City or town, state, and ZIP code or country 

Identifying number (see instructions) 

Shareholder tax year: calendar year 20 or other tax year 

beginning , 20 and ending , 20 .

Check type of shareholder filing the return: Individual Corporation Partnership S Corporation Nongrantor Trust Estate

Name of passive foreign investment company (PFIC) or qualified electing fund (QEF) 

Address (Enter number, street, city or town, and country.) 

Employer identification number (if any) 

Reference ID number (see instructions) 

Tax year of PFIC or QEF: calendar year 20 or other tax year

beginning , 20 and

ending , 20 .

Part I Summary of Annual Information Part I is reserved for future use (see instructions).

Provide the following information with respect to all shares of the PFIC held by the shareholder: 

1 Description of each class of shares held by the shareholder: 

Check if shares jointly owned with spouse.

2 Date shares acquired during the taxable year, if applicable:

3 Number of shares held at the end of the taxable year:

4 Value of shares held at the end of the taxable year (check the appropriate box, if applicable):

(a) $0-50,000 (b) $50,001-100,000 (c) $100,001-150,000 (d) $150,001-200,000

(e) If more than $200,000, list value:

5 Type of PFIC and amount of any excess distribution or gain treated as an excess distribution 

under section 1291, inclusion under section 1293, or inclusion or deduction under section 1296:

(a) Section 1291 $

(b) Section 1293 (Qualified Electing Fund) $

(c) Section 1296 (Mark to Market) $

Part II Elections (See instructions.) 

A Election To Treat the PFIC as a QEF. I, a shareholder of a PFIC, elect to treat the PFIC as a QEF. Complete lines 6a through 7c of Part III. 

B Election To Extend Time For Payment of Tax. I, a shareholder of a QEF, elect to extend the time for payment of tax on the undistributed 

earnings and profits of the QEF until this election is terminated. Complete lines 8a through 9c of Part III to calculate the tax that may be deferred. 

Note: If any portion of line 6a or line 7a of Part III is includible under section 951, you may not make this election. Also, see sections 1294(c) 

and 1294(f) and the related regulations for events that terminate this election. 

C Election To Mark-to-Market PFIC Stock. I, a shareholder of a PFIC, elect to mark-to-market the PFIC stock that is marketable within the 

meaning of section 1296(e). Complete Part IV. 

D Deemed Sale Election. I, a shareholder on the first day of a PFIC’s first tax year as a QEF, elect to recognize gain on the deemed sale of my 

interest in the PFIC. Enter gain or loss on line 15f of Part V. 

E Deemed Dividend Election. I, a shareholder on the first day of a PFIC’s first tax year as a QEF that is a controlled foreign corporation (CFC), 

elect to treat an amount equal to my share of the post-1986 earnings and profits of the CFC as an excess distribution. Enter this amount on 

line 15e of Part V. If the excess distribution is greater than zero, also complete line 16 of Part V. 

F Election To Recognize Gain on Deemed Sale of PFIC. I, a shareholder of a former PFIC or a PFIC to which section 1297(d) applies, elect to 

treat as an excess distribution the gain recognized on the deemed sale of my interest in the PFIC on the last day of its last tax year as a PFIC 

under section 1297(a). Enter gain on line 15f of Part V. 

G Deemed Dividend Election With Respect to a Section 1297(e) PFIC. I, a shareholder of a section 1297(e) PFIC, within the meaning of 

Regulations section 1.1297-3(a), elect to make a deemed dividend election with respect to the Section 1297(e) PFIC. My holding period in the 

stock of the Section 1297(e) PFIC includes the CFC qualification date, as defined in Regulations section 1.1297-3(d). Enter the excess 

distribution on line 15e, Part V. If the excess distribution is greater than zero, also complete line 16, Part V.

H Deemed Dividend Election With Respect to a Former PFIC. I, a shareholder of a former PFIC, within the meaning of Regulations section 

1.1298-3(a), elect to make a deemed dividend election with respect to the former PFIC. My holding period in the stock of the former PFIC 

includes the termination date, as defined in Regulations section 1.1298-3(d). Enter the excess distribution on line 15e, Part V. If the excess 

distribution is greater than zero, also complete line 16, Part V.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 64174H Form 8621 (Rev. 12-2012) 
Form 8621 (Rev. 12-2012) Page 2 

Part III Income From a Qualified Electing Fund (QEF). All QEF shareholders complete lines 6a through 7c. If you are making 

Election B, also complete lines 8a through 9c. (See instructions.) 

6a Enter your pro rata share of the ordinary earnings of the QEF . . . . . . 6a 

b Enter the portion of line 6a that is included in income under section 951 or that 

may be excluded under section 1293(g) . . . . . . . . . . . . 6b 

c Subtract line 6b from line 6a. Enter this amount on your tax return as ordinary income . . . . . . . . 6c 

7a Enter your pro rata share of the total net capital gain of the QEF . . . . . 7a 

b Enter the portion of line 7a that is included in income under section 951 or that 

may be excluded under section 1293(g) . . . . . . . . . . . . 7b 

c Subtract line 7b from line 7a. This amount is a net long-term capital gain. Enter this amount in Part II of the 

Schedule D used for your income tax return. (See instructions.) . . . . . . . . . . . . . . 7c 

8a Add lines 6c and 7c . . . . . . . . . . . . . . . . . . . . . . . . . . . 8a 

b Enter the total amount of cash and the fair market value of other property distributed or 

deemed distributed to you during the tax year of the QEF. (See instructions.) . . . 8b 

c Enter the portion of line 8a not already included in line 8c that is attributable to shares in 

the QEF that you disposed of, pledged, or otherwise transferred during the tax year . . 8c

d Add lines 8b and 8c . . . . . . . . . . . . . . . . . . . . . . . . . . . 8d 

e Subtract line 8d from line 8a, and enter the difference (if zero or less, enter amount in brackets) . . . . . 8e 

Important: If line 8e is greater than zero, and no portion of line 6a or 7a is includible in income under section 

951, you may make Election B with respect to the amount on line 8e. 

9a Enter the total tax for the tax year (See instructions.) . . . . . . . . 9a 

b Enter the total tax for the tax year determined without regard to the amount 

entered on line 8e . . . . . . . . . . . . . . . . . . . 9b 

c Subtract line 9b from line 9a. This is the deferred tax, the time for payment of which is extended by 

making Election B. See instructions . . . . . . . . . . . . . . . . . . . . . . 9c 

Part IV Gain or (Loss) From Mark-to-Market Election (See instructions.) 

10a Enter the fair market value of your PFIC stock at the end of the tax year . . . . . . . . . . . . 10a

b Enter your adjusted basis in the stock at the end of the tax year . . . . . . . . . . . . . . 10b

c Subtract line 10b from line 10a. If a gain, do not complete lines 11 and 12. Include this amount as ordinary 

income on your tax return. If a loss, go to line 11 . . . . . . . . . . . . . . . . . . . 10c

11 Enter any unreversed inclusions (as defined in section 1296(d)) . . . . . . . . . . . . . . 11

12 Enter the loss from line 10c, but only to the extent of unreversed inclusions on line 11. Include this amount as 

an ordinary loss on your tax return . . . . . . . . . . . . . . . . . . . . . . . 12

13 If you sold or otherwise disposed of any section 1296 stock (see instructions) during the tax year:

a Enter the fair market value of the stock on the date of sale or disposition . . . . . . . . . . . 13a

b Enter the adjusted basis of the stock on the date of sale or disposition . . . . . . . . . . . . 13b

c Subtract line 13b from line 13a. If a gain, do not complete line 14. Include this amount as ordinary income on 

your tax return. If a loss, go to line 14 . . . . . . . . . . . . . . . . . . . . . . 13c 

14a Enter any unreversed inclusions (as defined in section 1296(d)) . . . . . . . . . . . . . . 14a 

b Enter the loss from line 13c, but only to the extent of unreversed inclusions on line 14a. Include this amount as 

an ordinary loss on your tax return. If the loss on line 13c exceeds unreversed inclusions on line 14a, complete 

line 14c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14b 

c 

 

Enter the amount by which the loss on line 13c exceeds unreversed inclusions on line 14a. Include this amount 

on your tax return according to the rules generally applicable for losses provided elsewhere in the Code and 

regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14c 

Note. See instructions in case of multiple dispositions.

Form 8621 (Rev. 12-2012) 
Form 8621 (Rev. 12-2012) Page 3

Part V Distributions From and Dispositions of Stock of a Section 1291 Fund (See instructions.)

Complete a separate Part V for each excess distribution (see instructions). 

15 a Enter your total distributions from the section 1291 fund during the current tax year with respect to the 

applicable stock. If the holding period of the stock began in the current tax year, see instructions . . . . 15a 

b 

 

 

Enter the total distributions (reduced by the portions of such distributions that were excess distributions but 

not included in income under section 1291(a)(1)(B)) made by the fund with respect to the applicable stock for 

each of the 3 years preceding the current tax year (or if shorter, the portion of the shareholder’s holding period 

before the current tax year) . . . . . . . . . . . . . . . . . . . . . . . . . 15b 

c Divide line 15b by 3. (See instructions if the number of preceding tax years is less than 3.) . . . . . . 15c 

d Multiply line 15c by 125% (1.25) . . . . . . . . . . . . . . . . . . . . . . . 15d 

e 

 

 

Subtract line 15d from line 15a. This amount, if more than zero, is the excess distribution with respect to the 

applicable stock. If zero or less and you did not dispose of stock during the tax year, do not complete the rest 

of Part V. See instructions if you received more than one distribution during the current tax year. Also, see 

instructions for rules for reporting a nonexcess distribution on your income tax return . . . . . . . . 15e 

f Enter gain or loss from the disposition of stock of a section 1291 fund or former section 1291 fund. If a gain, 

complete line 16. If a loss, show it in brackets and do not complete line 16 . . . . . . . . . . . 15f 

16 a 

 

Attach a statement for each distribution and disposition. Show your holding period for each share of stock or 

block of shares held. Allocate the excess distribution to each day in your holding period. Add all amounts that 

are allocated to days in each tax year. 

b Enter the total of the amounts determined in line 16a that are allocable to the current tax year and tax years before the 

foreign corporation became a PFIC (pre-PFIC tax years). Enter these amounts on your income tax return as other income 16b 

c Enter the aggregate increases in tax (before credits) for each tax year in your holding period (other than the 

current tax year and pre-PFIC years). (See instructions.) . . . . . . . . . . . . . . . . 16c

d Foreign tax credit. (See instructions.) . . . . . . . . . . . . . . . . . . . . . . 16d 

e Subtract line 16d from line 16c. Enter this amount on your income tax return as “additional tax.” (See instructions.) . 16e

f Determine interest on each net increase in tax determined on line 16e using the rates and methods of section 

6621. Enter the aggregate amount of interest here. (See instructions.) . . . . . . . . . . . . 16f 

Part VI Status of Prior Year Section 1294 Elections and Termination of Section 1294 Elections 

Complete a separate column for each outstanding election. Complete lines 25 and 26 only if there is a partial 

termination of the section 1294 election. 

(i) (ii) (iii) (iv) (v) (vi) 

17 Tax year of outstanding 

election . . . . . . .

18 Undistributed earnings to 

which the election relates .

19 Deferred tax . . . . .

20 Interest accrued on deferred 

tax (line 19) as of the filing date 

21 Event terminating election .

22 

 

Earnings distributed or 

deemed distributed during the 

tax year . . . . . . .

23 Deferred tax due with this 

return . . . . . . .

24 Accrued interest due with this 

return . . . . . . .

25 Deferred tax outstanding after 

partial termination of election .

26 Interest accrued after partial 

termination of election . .

Form 8621 (Rev. 12-2012)