Return by a Shareholder of a Passive Foreign

Investment Company or Qualified Electing Fund

Form 8621 OMB No. 1545-1002

(Rev. October 1991) Expires 4-30-94

Attachment 

Sequence No. 69 Department of the Treasury

Internal Revenue Service © See separate instructions.

Name of shareholder Identifying number (see instructions)

Number, street, and room or suite no. (If a P.O. box, see separate instructions on page 2.) Your tax year: Calendar year 19 or other tax year

beginning 19 and ending 19 .

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 19 or other tax year

Elections (See Specific Instructions for Information To Attach When Making an Election.)

1

2

3

4

Income From a Qualified Electing Fund (QEF). All QEF shareholders complete lines 6a through 7c. Those making the

line 4 election also complete lines 8a through 9c.

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

Enter the portion of line 6a that is included in income under section 551 or 951 or that may be

excluded under section 1293(g) 6b

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

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

Enter the portion of line 7a that is included in income under section 551 or 951 or that may be

excluded under section 1293(g)

6b

7b

Subtract line 7b from line 7a. This amount is long-term capital gain. Enter this amount in Part

II of the Schedule D used for your income tax return

6c

7c

Add lines 6c and 7c 8a

7a

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 for line 8b.)

7b

8b

Enter the portion of line 8a to the extent not already included in line 8b that is attributable to

shares in the QEF that you disposed of, pledged, or otherwise transferred during the tax year

7c

8c

Add lines 8b and 8c 8d

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

If any portion of line 6a or 7a is includible under section 551 or 951, you may not make the

line 4 election. If no portion of line 6a or line 7a is includible in income under section 551 or

951 and line 8e is greater than zero, you may make the line 4 election with respect to the

amount on line 8e.

Computation of Tax for Which the Time for Payment Is Extended

Enter the total tax for total taxable income for the tax year 9a

8a

b Enter the total tax for the tax year determined without regard to the amount entered on line 8e 9b

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

by making the line 4 election. See instructions

c

9c

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 8621 (Rev. 10-91)

Part I

Part II

beginning 19 and ending 19 .

5

6a

8b

8c

8d

8e

9a

Cat. No. 64174H

I, a shareholder of a PFIC, elect to treat the PFIC as a QEF. (Section 1295.)

Complete Part II.

I, a shareholder on the first day of the first tax year of a PFIC as a QEF, elect to recognize gain on the deemed sale of my

interest in the PFIC. (Section 1291(d)(2)(A).)

Enter gain or loss on line 10f. Show loss in brackets. Loss is not recognized. If a gain, complete the rest of Part III.

I, a shareholder on the first day of the first tax year of a PFIC 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. (Section

1291(d)(2)(B).)

Enter this amount on line 10e. See Specific Instructions for tax years over which the excess distribution is allocated.

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 terminated. (Section 1294.)

See sections 1294(c) and 1294(f) for events that terminate this election.

I, a shareholder of a former PFIC, elect to recognize gain on the deemed sale of my interest in the PFIC on the last day of

the last tax year as a PFIC. (Section 1297(b)(1).)

Enter gain or loss on line 10f. Show loss in brackets. Loss is not recognized. If a gain, complete the rest of Part III.
Form 8621 (Rev. 10-91) Page 2

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

Enter the total amount of distributions made to you by the PFIC 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 to the

extent there are accumulated earnings and profits

10a

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 period before the current tax year)

b

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

Multiply line 10c by 125%. Enter the lesser of line 10a or line 10d as a dividend on your income

tax return

d

Subtract line 10d from line 10a. If zero or less and you did not dispose of stock during the tax year,

do not complete the rest of Part III. The amount on line 10e, if more than zero, is the total excess

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

e

Enter the gain realized on the disposition of your interest in the nonqualified fund, which is

treated as an excess distribution

f

On an attached statement for each distribution and disposition, show your holding period for

each share of stock or block of shares held and:

11

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

allocated to days in each tax year.

a

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

To determine the increase in tax for each tax year in your holding period (other than the current

tax year and pre-PFIC years), multiply the amount allocated to each tax year by the highest

rate of tax under section 1 or section 11, whichever applies, in effect for that tax year. Enter

the aggregate increases in taxes (before credits) here

c

11c

d Foreign tax credit 11d

Subtract the amount on line 11d from the amount on line 11c. Enter this amount on your income

tax return as “additional tax”

e

11e

Determine interest on each net increase in tax (increase in tax less any foreign tax credit)

determined in line 11e by using the rates and method contained in section 6621 and enter the

aggregate amount of interest here

f

11f

Status of Section 1294 Elections and Termination of Section 1294 Elections

Complete a separate column for each outstanding election.

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

,19 1 Tax year of outstanding

election

Undistributed earnings to

which the election relates

2

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

Deferred tax due with this

return

7

Accrued interest due with this

return

8

Complete lines 9 and 10 only if

there is a partial termination of

the section 1294 election

Portion of deferred tax outstanding

after partial termination of section

1294 election

9

Portion of interest accrued

after partial termination of

section 1294 election

10

Part IV

Part III

10a

10c

10d

10e

10f

11b

,19 ,19 ,19 ,19 ,19