OMB No. 1545-0216 International Boycott Report Form 5713

(Rev. January 1997)

For tax year beginning , 19 ,

and ending , 19 . File in Duplicate

Department of the Treasury (See Instruction G) Internal Revenue Service © Controlled groups, see specific instructions.

Name Identifying number

Number, street and room or suite no. (If a P.O. box, see page 2 of instructions.)

City or town, state and ZIP code

Address of service center where your tax return is filed

Type of filer (check one):

Individual Partnership Corporation Trust Estate Other

1 Individuals—Enter adjusted gross income from your tax return (see instructions)

2 Partnerships and corporations:

a Partnerships—Enter each partner’s name and identifying number.

Corporations—Enter the name and employer identification number of each member of the controlled group (as defined in

section 993(a)(3)). Do not list members included in the consolidated return; instead, attach a copy of Form 851. List all

other members of the controlled group not included in the consolidated return.

b

If you list any corporations below or if you attach Form 851, you must designate a ‘‘common taxable year.’’ Enter on

line 4b the name and employer identification number of the corporation whose taxable year is designated.

Name Identifying number

If more space is needed, attach additional sheets and check this box ©

Code Description

c Enter principal business activity code and description (see instructions)

d IC-DISCs—Enter principal product or service code and description (see instructions)

3 Partnerships—Each partnership filing Form 5713 must give the following information:

a Partnership’s total assets (see instructions)

b Partnership’s ordinary income (see instructions)

4 Corporations—Each corporation filing Form 5713 must give the following information:

a Type of form filed (Form 1120, 1120-F, 1120-FSC, 1120-IC-DISC, 1120-L, 1120-PC, etc.)

b Common taxable year election (see instructions)

(1) Name of corporation ©

(2) Employer identification number

(3) Common taxable year beginning , 19 , and ending , 19 .

c Corporations filing this form enter:

(1) Total assets (see instructions)

(2) Taxable income before net operating loss and special deductions (see instructions)

5 Estates or trusts—Enter total income (Form 1041, page 1)

6 Enter the total amount (before reduction for boycott participation or cooperation) of the following tax benefits (see instructions):

a Foreign tax credit

b Deferral of earnings of controlled foreign corporations

c Deferral of IC-DISC income

d Exempt FSC income

Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct, and complete.

Signature Date Title

For Paperwork Reduction Act Notice, see page 1 of the Instructions. Form 5713 (Rev. 1-97)

Please

Sign

Here © ©

Cat. No. 12030E
Form 5713 (Rev. 1-97) Page 2

Yes No 7 The following information must be submitted by every person filing Form 5713 (see specific instructions):

Are you a United States shareholder (as defined in section 951(b)) of any foreign corporation (including a FSC

that does not use the administrative pricing rules) that had operations reportable under section 999(a)?

a

b If “Yes,” is any foreign corporation a controlled foreign corporation (as defined in section 957(a))?

c Do you own any stock of an IC–DISC?

d Do you claim any foreign tax credit?

Do you control (within the meaning of section 304(c)) any corporation (other than a corporation included in this

report) that has operations reportable under section 999(a)?

e

If “Yes,” did that corporation participate in or cooperate with an international boycott at any time during its tax

year that ends with or within your tax year?

Are you controlled (within the meaning of section 304(c)) by any person (other than a person included in this

report) who has operations reportable under section 999(a)?

f

If “Yes,” did that person participate in or cooperate with an international boycott at any time during its tax year

that ends with or within your tax year?

g Are you treated under section 671 as the owner of a trust that has reportable operations under section 999(a)?

h Are you a partner in a partnership that has reportable operations under section 999(a)?

i Are you a foreign sales corporation (FSC) (as defined in section 922(a))?

Operations in or related to a Boycotting Country (See instructions)

Yes No

Boycott of Israel—Did you have any operations in or related to any country (or with the government, a company,

or a national of that country) associated in carrying out the boycott of Israel which is on the list maintained by

the Secretary of the Treasury under section 999(a)(3)? (See Instruction I 1.)

8

If “Yes,” enter name of the country, identifying number of person having operations, principal business activity code, a

description of the principal business activity; and if you are an IC-DISC, enter the product code. If more space is needed,

attach additional sheets using the exact format and check this box ©

Principal business activity IC-DISCs

only—Enter

product code

Identifying number of Name of country person having operations Code Description

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

a

b

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Part I
Form 5713 (Rev. 1-97) Page 3

Yes No Non-listed countries boycotting Israel—Did you have operations in any non-listed country which you know or

have reason to know requires participation in or cooperation with an international boycott directed against Israel?

9

If “Yes,” enter the country, identifying number of person having operations, the principal business activity code, a

description of the principal business activity, and if you are an IC-DISC, enter the product code. If more space is needed,

attach additional sheets using the exact format and check this box ©

IC-DISCs

only—Enter

product code

Identifying number of

person having operations

Principal business activity

Name of country Code Description

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

a

b

c

d

e

f

g

h

Yes No Boycotts other than the boycott of Israel—Did you have operations in any other country which you know or have reason

to know requires participation in or cooperation with an international boycott other than the boycott of Israel?

10

If “Yes,” enter the country, identifying number of person having operations, the principal business activity code, a

description of the principal business activity, and if you are an IC-DISC, enter the product code. If more space is needed,

attach additional sheets using the exact format and check this box ©

IC-DISCs

only—Enter

product code

Identifying number of

person having operations

Principal business activity

Name of country Code Description

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

a

b

c

d

e

f

g

h

Yes No

11 Were you requested to participate in or cooperate with an international boycott?

If ‘‘Yes,’’ attach a copy (in English) of any and all such requests received during your tax year. If the request was

in a form other than a written request, attach a separate sheet explaining the nature and form of any and all

such requests. (See instructions.)

12 Did you participate in or cooperate with an international boycott?

If “Yes,” attach a copy (in English) of any and all boycott clauses agreed to, and attach a general statement of the agreement.

If the agreement was in a form other than a written agreement, attach a separate sheet explaining the nature and form of

any and all such agreements. (See instructions.)

Note: If the answer to either question 11 or 12 is “Yes,” you must complete the rest of Form 5713. If you answered “Yes” to question

12, you must complete Schedules A and C or B and C (Form 5713).
Form 5713 (Rev. 1-97) Page 4

Requests for and acts of participation in or cooperation with an International

Boycott

13a Did you receive requests to enter into, or did you enter into any agreement (See instructions F 4 and F 5.):

Requests Agreements

Yes No Yes No

As a condition of doing business directly or indirectly within a country or with the government,

a company, or a national of a country to—

Refrain from doing business with or in a country which is the object of an international

boycott or with the government, companies, or nationals of that country?

(i)

Refrain from doing business with any United States person engaged in trade in a country

which is the object of an international boycott or with the government, companies, or

nationals of that country?

(ii)

Refrain from doing business with any company whose ownership or management is made up, all

or in part, of individuals of a particular nationality, race, or religion, or to remove (or refrain from

selecting) corporate directors who are individuals of a particular nationality, race, or religion?

(iii)

(iv) Refrain from employing individuals of a particular nationality, race, or religion?

(2) As a condition of the sale of a product to the government, a company, or a national of a country,

to refrain from shipping or insuring products on a carrier owned, leased, or operated by a person

who does not participate in or cooperate with an international boycott?

b Requests and agreements—If the answer to any part of 13a is “Yes,” indicate below: the country, the identifying number

of the person receiving the request or having the agreement, principal business activity code, description of the principal

business activity, the number and the number code indicating the type of participation or cooperation requested or agreed

to. Also, if you are an IC-DISC, enter the product code in column (5). (See instructions.) If more space is needed, attach

additional sheets using the exact format and check this box ©

IC-DISCs Type of cooperation or participation

only—

Enter

product

code

Identifying number of

person receiving the

request or having the

agreement

Principal business activity

Name of country Number of requests Number of agreements

Code Description Total Code Total Code

(1) (2) (3) (4) (5) (6) (7) (8) (9)

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(1)

Part II