8621 Return by a Shareholder of a Passive Foreign

Form ves . OMB No. 1545-1002
(Rev. April 1989) Investment Company or Qualified Electing Fund Expires 9-30-91
Department of the Treasury i i . Attachment

Internal Revenue Serves > See separate instructions. Sequence No. 69
Name of shareholder Identifying number (see instructions)
Number and street

Enter your tax year: Calendar year 19. Othertax year
beginning 19 andending 19

City or town, state, and ZIP code or country

Check type of shareholder filing the return: [_] individual [] corporation [] partnership [_] Scorporation [_] nongrantor trust [] estate

Name of passive foreign investment company or qualified electing fund Employer identification number (if any)
Address (Enter number, street, city or town, and country.) Tax year of Company or Fund: Calendar year 19. Other tax year,
beginning 19° and ending

EEGg] Elections

1 LC |, ashareholder on the first day of the first tax year of a passive foreign investment company as a qualified electing fund, elect to

recognize gain on the deemed sale of my interest in the company on that date.

Gain is treated as an excess distribution. Determine your tax liability in Part Il]; enter the amount of gain on line 9f. If the
deemed sale results in a loss, enter the loss in brackets on line 9f. The loss is shown for information purposes only.

See section 1291(d)(2)(A) and Temporary Regulations section 1.1291-10T(d) for information that must be submitted when
making this election.

21 |, ashareholder on the first day of the first tax year of a passive foreign investment company as a qualified electing fund that is a

controlled foreign corporation, elect to treat an amount equal to the post-1986 earnings and profits attributable to the stock as an
excess distribution under section 1291.

Enter this amount on line 9e. Only use tax years beginning after 1986 to determine the years over which the excess distribution
is allocated in line 10a. See section 1291(d)(2)(B).

3 C1 |, ashareholder of a qualified electing fund, elect to extend the time for payment of tax on the undistributed earnings and profits of

the fund until terminated. See section 1294(c) and (f) and Temporary Regulations section 1.1294-1T(e) for termination events.
See Temporary Regulations section 1.1294-1T(d)(2) for information that must be submitted when making this election.

41 |,ashareholder of a former passive foreign investment company, as described in section 1297(b)(1), elect to recognize gain on the

deemed sale of my interest in the company as of the last day of the last tax year as a passive foreign investment company.
Gain is treated as an excess distribution. Determine your tax liability in Part III; enter the gain on line 9f. If the deemed sale
results ina loss, enter the loss in brackets on line 9f. The loss is shown for information purposes only.
See Temporary Regulations section 1.1297-3T(b)(2) for information that must be submitted when making this election.

Income From a Qualified Electing Fund (QEF). All QEF shareholders complete lines 5a through 6c. Those making the line
3 election also complete lines 7a through 8c. See the instructions for additional information that must be attached to Form 8621.

5a
5b

5c
6i
6b

Cy

7
7b

7

e

7
7e

os

5a

Enter your pro rata share of the ordinary earnings of the QEF . :
Enter the portion of line 5a that is included in income under section 551 or 951 0 or that may ‘be
excluded under section 1293(g). . . .. . 2... 5b
Subtract line 5b from line 5a. Enter this amount on your tax return a as “other it income” .. . [Se
Enter your pro rata share of the net capital gain ofthe QEF. . . 6a
Enter the portion of line 6a that is included in income under section 551 or "981 0 or that may ‘be
excluded under section 1293(g). . . . . . soe Sb
Subtract line 6b from line 6a. This amount is long- term capital gain. ‘Enter this amount in Part I of the
Schedule D used foryourincometaxreturn 2 2 2 we 6c
AddlinesScand6c. . . . 1 ww Ja
Enter the total amount of cash and the fair market value of other property distributed or “deemed WI,
distributed to you during the tax yearoftheQEF. . . . 7b
Enter the portion of line 7a to the extent not already included i in ‘line Ib that i is attributable to shares (im
c

in the QEF that you disposed of, pledged, or otherwise transferred during the tax year . woe
Addlines7band7c. . . . tone wae. Ld
Subtract line 7d from line 7a, and. enter the difference (but not less than zero) here

If any portion of line 5a or 6a is includible under section 551 or 951, you may not make the ‘ine 3
election. If no portion of line 5a or line 6a is includible in income under section 551 or 951 and line
7e is greater than zero, you may make the line 3 election with respect to the amount on line 7e.

Computation of Amount of Tax the Time for Payment of Which Is Extended

Enter the total tax for total taxable income forthetaxyear. . . 6 2. 6 ee ee ee 8a
Enter the total tax for the tax year determined without regard to the amount entered on line Te Sb

Subtract line 8b from line 8a. This is the deferred tax, the time for payment of which is extended by
making the line 3 election. See instructions . . . .. . | 8

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 8621 (Rev. 4-89)


Form 8621 (Rev. 4-89)

Page 2

Za4l8 Distributions and Disposition of Stock in a Nonqualified Fund (See instructions.)

9a Enter the total amount of distributions made to you by the passive foreign investment company
during the tax year. If the holding period of the stock began in the tax year, enter this amount as a

dividend on your tax return. See instructions .

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period before the currenttaxyear) . . . .

°

income tax return

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distribution. See instructions if you received more than one distribution during the tax year .

an excess distribution

10 Onan attached statement for each distribution ‘and disposition, show your holding period for each

share of stock or block of shares held and:

to days in each tax year.

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years). Enter these amounts on your income tax return as “other income”

c To determine the increase in tax for each tax year in your holding period (other than the current tax
year and prePFIC years), multiply the amount allocated to each tax year by the highest rate of tax
under section 1 or section 11, whichever is applicable, in effect for that tax year. Enter the segregate

increases in taxes (before credits)here . . . ray eee ee
Foreign tax credit. See instructions .

~

Enter the total amount of 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 company for each
of the 3 years preceding the current tax year (or if shorter, the portion of the shareholder's holding

Divide the amount on line 9b by 3 (but see instructions if the number of preceding tax years is less than 3)
d Multiply the amount on line 9c by 125%. Enter the lesser of line 9a or line 9d as a dividend on your

Subtract line 9d from line ga. If zero or less ss and. you didn not dispose o of stock ‘during t the tax year, do
not complete the rest of Part Ill. The amount on line Ye, if more than zero, is the total excess

Enter the gain realized on the Gisposition of your interest in the nonqualifed fund, which is treated as

Allocate the excess distribution to each day in your holding period. Add all amounts that are allocated

Enter the total of the amounts determined in line 10a that are allocable to the current tax year and
tax years before the foreign corporation became a passive foreign investment company (orePFIC tax

Subtract the amount on line 10d from the amount 0 on line ‘toe. Enter this ‘amount 0 ‘on your income tax

9a

9b

9c

9d

10c

10d

return as “additional tax.” See instructions 10e
Determine interest on each net increase in tax (increase i in tax lessa any foreign tax credit) determined.
in line 10e by using the rates and method contained in section 6621 and enter the aggregate amount
of interest here. See instructions . : 10f

Status of Section 1294 Elections and Termination of Section 1294 Elections
Complete a separate column for each outstanding election.

(0) (i) (iii)

1 Tax year of outstanding election | ------- : : -,19....

2  Undistributed earnings to which
the election relates

3 Deferred tax

4 Interest accrued as of the filing
date

5 Event terminating election

6 Earnings distributed or deemed
distributed during the tax year

7 Deferred tax due with this return

8 Accrued interest due with this
return

Complete lines 9 and 10 onlyif 77
there is a partial termination of
the section 1294 election

9 Portion of deferred tax outstanding
after partial termination of section
1294 election

10 Portion of interest accrued after
partial termination of section
1294 election