OMB No. 1545-1910

Information Return of U.S. Persons With

Respect To Foreign Disregarded Entities Form 8858

(December 2004)

Information furnished for the foreign disregarded entity’s annual accounting period (see

instructions) beginning , 20 , and ending , 20 Department of the Treasury

Internal Revenue Service

Name of person filing this return Filer’s identifying number

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

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 disregarded entity b U.S. identifying number, if any

Effective date as foreign

disregarded entity

e

Country in which principal h Functional currency

business activity is conducted

If benefits under a U.S. tax treaty were claimed with respect to g

income of the foreign disregarded entity, enter the treaty and article

number

a

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

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

the United States

For Paperwork Reduction Act Notice, see the separate instructions. Form 8858 (12-2004)

 See separate instructions.

Cat. No. 21457L

f Principal business

activity

i

c Country(ies) under whose laws organized and entity type under local tax law

Name and address (including corporate department, if applicable) of

person(s) with custody of the books and records of the foreign disregarded

entity, and the location of such books and records, if different

a

3 For the tax owner of the foreign disregarded entity (if different from the filer) provide the following:

Name and address b Annual accounting period covered by the

return (see instructions)

a

4 For the direct owner of the foreign disregarded entity (if different from the tax owner) provide the following:

Name and address b Country under whose laws organized

c

d Country under whose laws organized e Functional currency

c

d Functional currency

5 Attach an organizational chart that identifies the name, placement, percentage of ownership, tax classification, and country of organization of all entities in

the chain of ownership between the tax owner and the foreign disregarded entity, and the chain of ownership between the foreign disregarded entity and

each entity in which the foreign disregarded entity has a 10% or more direct or indirect interest. 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 or the average exchange rate determined

under section 989(b)). If the functional currency is the U.S. dollar, complete only the U.S. Dollars column. See instructions

for special rules for foreign disregarded entities that use DASTM. 

If you are using the average exchange rate (determined under section 989(b)), check the following box

Income Statement (see instructions)

1 Gross receipts or sales (net of returns and allowances) 1

2 Cost of goods sold 2

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

4 Other income 4

5 Total income (add lines 3 and 4) 5

6 Total deductions 6

7 Other adjustments 7

8 Net income (loss) per books 8

Schedule C

Functional Currency U.S. Dollars

U.S. identifying number, if any

U.S. identifying number, if any

d Date(s) of organization

Attachment

Sequence No. 140
Form 8858 (12-2004) Page 2

Section 987 Gain or Loss Information

1 Remittances from the foreign disregarded entity 1

2 Section 987 gain (loss) of recipient 2

3 Were all remittances from the foreign disregarded entity treated as made to the direct owner?

Did the tax owner change its method of accounting for section 987 gain or loss with respect to

remittances from the foreign disregarded entity during the tax year?

4

Schedule C-1

(a)

Amount stated in

functional currency of

foreign disregarded entity

(b)

Amount stated in

functional currency

of recipient

Form 8858 (12-2004)

Yes No

Balance Sheet

(b)

End of annual

accounting period

(a)

Beginning of annual

accounting period

Assets

1 Cash and other current assets 1

2 Other assets 2

3 3

4 4

5 5

6

Total assets

6

Liabilities 

Owner’s equity

Total liabilities and owner’s equity

Liabilities and Owner’s Equity

Schedule F

Important: Report all amounts in U.S. dollars computed in functional currency and translated into U.S. dollars in

accordance with U.S. GAAP. See instructions for an exception for foreign disregarded entities that use DASTM.

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

2 Total net additions

3 Total net subtractions

4 Current earnings and profits (or taxable income—see instructions) (line 1 plus line 2 minus line 3)

Current earnings and profits (or taxable income) in U.S. dollars (line 6 translated at the average

exchange rate determined under section 989(b) and the related regulations (see instructions))

Schedule H

6

Current Earnings and Profits or Taxable Income (see instructions)

Important: Enter the amounts on lines 1 through 6 in functional currency.

Schedule G Other Information

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

During the tax year, did the foreign disregarded entity own at least a 10% interest, directly or indirectly,

in any foreign partnership?

1

2

3

Yes No

Answer the following question only if the foreign disregarded entity made its election to be treated as

disregarded from its owner during the tax year: Did the tax owner claim a loss with respect to stock or

debt of the foreign disregarded entity as a result of the election?

4 Answer the following question only if the foreign disregarded entity is owned directly or indirectly by a

domestic corporation and the foreign disregarded entity incurred a net operating loss for the tax year: Is

the foreign disregarded entity a separate unit as defined in Regulations sections 1.1503-2(c)(3) and (4)?

(If yes, see the instructions)

5 Answer the following question only if the tax owner of the foreign disregarded entity is a controlled foreign

corporation ( CFC): Were there any intracompany transactions between the foreign disregarded entity and

the CFC or any other branch of the CFC during the tax year, in which the foreign disregarded entity acted

as a manufacturing, selling, or purchasing branch?

7

Combine lines 4 and 5

Enter exchange rate used for line 7 

1

2

3

4

6

7

5 DASTM gain or loss (if applicable) 5

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