Return by a Shareholder of a Passive Foreign

Investment Company or Qualified Electing Fund Form 8621

(Rev. December 2004)

Attachment 

Sequence No. 69 Department of the Treasury

Internal Revenue Service See separate instructions.

Name of shareholder Identifying number (see page 2 of instructions)

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

City or town, state, and ZIP code or country

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) Employer identification number (if any)

Address (Enter number, street, city or town, and country.) Tax year of company or fund: calendar year 20 or other

tax year beginning , 20 and

ending , 20 .

Elections (See instructions.)

A

B

C

D

Income From a Qualified Electing Fund (QEF). All QEF shareholders complete lines 1a through 2c. If you are making

Election D, also complete lines 3a through 4c. (See page 5 of instructions.)

Enter your pro rata share of the ordinary earnings of the QEF 1a

Enter the portion of line 1a that is included in income under

section 551 or 951 or that may be excluded under section 1293(g) 1b

Subtract line 1b from line 1a. Enter this amount on your tax return as dividend income 1c

Enter your pro rata share of the total net capital gain of the QEF 2a

Enter the portion of line 2a that is included in income under

section 551 or 951 or that may be excluded under section 1293(g)

b

2b

Subtract line 2b from line 2a. 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.)

c

2c

Add lines 1c and 2c 3a

2a

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.)

b

3b

Enter the portion of line 3a not already included in line 3b that is

attributable to shares in the QEF that you disposed of, pledged,

or otherwise transferred during the tax year

c

3c

Add lines 3b and 3c 3d

3e Subtract line 3d from line 3a, and enter the difference (if zero or less, enter amount in brackets)

Important: If line 3e is greater than zero, and no portion of line 1a or 2a is includible in income

under section 551 or 951, you may make Election D with respect to the amount on line 3e.

Enter the total tax for the tax year (See instructions.) 4a

3a

4b

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

the amount entered on line 3e

b

Subtract line 4b from line 4a. This is the deferred tax, the time for payment of which is

extended by making Election D. See instructions

c

4c

For Paperwork Reduction Act Notice, see page 7 of separate instructions. Form 8621 (Rev. 12-2004)

Part I

Part II

E

1a

b

c

d

e

4a

Cat. No. 64174H

Election To Treat the PFIC as a QEF. I, a shareholder of a PFIC, elect to treat the PFIC as a QEF. Complete lines 1a through 2c of Part II.

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 10f of Part IV.

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 10e of Part IV.

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 3a through 4c of Part II to

calculate the tax that may be deferred.

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

treat as an excess distribution the gain recognized on the deemed sale of my interest in the PFIC, or, if I qualify, my share of the PFIC’s post-1986

earnings and profits deemed distributed, on the last day of its last tax year as a PFIC under section 1297(a). Enter gain on line 10f of Part IV.

OMB No. 1545-1002

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 III.

F

Note: If any portion of line 1a or line 2a of Part II is includible under section 551 or 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.

Shareholder tax year: calendar year 20 or other tax year

beginning , 20 and ending , 20 .
Form 8621 (Rev. 12-2004) Page 2

Distributions From and Dispositions of Stock of a Section 1291 Fund (See page 6 of instructions.)

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

10a

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)

b

c Divide line 10b by 3. (See instructions if the number of preceding tax years is less than 3.)

d Multiply line 10c by 125% (1.25)

Subtract line 10d from line 10a. 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 IV. 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

e

Enter gain or loss from the disposition of stock of a section 1291 fund or former section 1291

fund. If a gain, complete line 11. If a loss, show it in brackets and do not complete line 11

f

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.

11a

Enter the total of the amounts determined in line 11a 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

b

10b

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.)

c

11c

d Foreign tax credit. (See instructions.) 11d

Subtract line 11d from line 11c. Enter this amount on your income tax return as “additional

tax.” (See instructions.)

e

11e

Determine interest on each net increase in tax determined on line 11e using the rates and

methods of section 6621. Enter the aggregate amount of interest here. (See instructions.)

f

11f

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

Complete a separate column for each outstanding election. Complete lines 9 and 10 only if there is a

partial termination of the section 1294 election.

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

1 Tax year of outstanding

election

Undistributed earnings to

which the election relates

2

3 Deferred tax

4 Interest accrued on deferred

tax (line 3) as of the filing date

5 Event terminating election

6 Earnings distributed or deemed

distributed during the tax year

Deferred tax due with this

return

7

Accrued interest due with

this return

8

Deferred tax outstanding after

partial termination of election

9

Interest accrued after partial

termination of election

10

Part IV

Part III

10a

10c

10d

10e

10f

11b

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

Part V

Gain or (Loss) From Mark-to-Market Election (See page 5 of instructions.)

5 Enter the fair market value of your PFIC stock at the end of the tax year 5

6 Enter your adjusted basis in the stock at the end of the tax year 6

Excess. Subtract line 6 from line 5. If a gain, stop here. Include this amount as ordinary income

on your tax return. If a loss, go to line 8

7

7

8 Enter any unreversed inclusions (as defined in section 1296(d)). See instructions. 8

9 Enter the smaller of line 7 or line 8. Include this amount as an ordinary loss on your tax return 9

Form 8621 (Rev. 12-2004)