Form 5472
(Rev. December 2018)
Department of the Treasury
Internal Revenue Service
Information Return of a 25% Foreign-Owned U.S. Corporation or a
Foreign Corporation Engaged in a U.S. Trade or Business
(Under Sections 6038A and 6038C of the Internal Revenue Code)
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Go to www.irs.gov/Form5472 for instructions and the latest information.
For tax year of the reporting corporation beginning , , and ending ,
Note: Enter all information in English and money items in U.S. dollars.
OMB No. 1545-0123
Part I Reporting Corporation (see instructions). All reporting corporations must complete Part I.
1a Name of reporting corporation
Number, street, and room or suite no. (if a P.O. box, see instructions)
City or town, state, and ZIP code (if a foreign address, see instructions)
1b Employer identification number
1c Total assets
$
1d Principal business activity
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1e Principal business activity code
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1f Total value of gross payments made or received
reported on this Form 5472. See instructions.
$
1g Total number of Forms 5472
filed for the tax year
1h Total value of gross payments made or received
reported on all Forms 5472. See instructions.
$
1i Check here if this is a consolidated filing
of Form 5472 . . . . . .
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1j Check here if this is the initial year for which the U.S.
reporting corporation is filing a Form 5472 . .
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1k Country of incorporation
1l Country(ies) under whose laws the reporting
corporation files an income
tax return as a resident
1m Principal country(ies) where business is conducted
2 Check here if, at any time during the tax year, any foreign person owned, directly or indirectly, at least 50% of (a) the total voting power of all
classes of the stock of the reporting corporation entitled to vote, or (b) the total value of all classes of stock of the reporting corporation
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3 Check here if the reporting corporation is a foreign-owned domestic disregarded entity (foreign-owned U.S. DE) treated as a corporation for
purposes of section 6038A. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part II 25% Foreign Shareholder (see instructions)
Check here if any direct (or ultimate indirect) 25% foreign shareholder listed in Part II is a surrogate foreign
corporation under section 7874(a)(2)(B).
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1a Name and address of direct 25% foreign shareholder
1b(1) U.S. identifying number, if any 1b(2) Reference ID number (see instructions) 1b(3) Foreign taxpayer identification number (FTIN), if any (see
instructions)
1c Principal country(ies) where
business is conducted
1d Country of citizenship,
organization, or incorporation
1e Country(ies) under whose laws the direct 25% foreign shareholder
files an income tax return as a resident
2a Name and address of direct 25% foreign shareholder
2b(1) U.S. identifying number, if any 2b(2) Reference ID number (see instructions) 2b(3) FTIN, if any (see instructions)
2c Principal country(ies) where
business is conducted
2d Country of citizenship,
organization, or incorporation
2e Country(ies) under whose laws the direct 25% foreign shareholder
files an income tax return as a resident
3a Name and address of ultimate indirect 25% foreign shareholder
3b(1) U.S. identifying number, if any 3b(2) Reference ID number (see instructions) 3b(3) FTIN, if any (see instructions)
3c Principal country(ies) where
business is conducted
3d Country of citizenship,
organization, or incorporation
3e Country(ies) under whose laws the ultimate indirect 25% foreign
shareholder files an income tax return as a resident
4a Name and address of ultimate indirect 25% foreign shareholder
4b(1) U.S. identifying number, if any 4b(2) Reference ID number (see instructions) 4b(3) FTIN, if any (see instructions)
4c Principal country(ies) where
business is conducted
4d Country of citizenship,
organization, or incorporation
4e Country(ies) under whose laws the ultimate indirect 25% foreign
shareholder files an income tax return as a resident
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 49987Y
Form
5472 (Rev. 12-2018)