SCHEDULE Q
(Form 1120-IC-DISC)
(Rev. September 2016)
Department of the Treasury
Internal Revenue Service
Borrower’s Certificate of Compliance
With the Rules for Producer’s Loans
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Attach to Form 1120-IC-DISC.
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Information about Form 1120-IC-DISC and its separate instructions is at www.irs.gov/form1120icdisc.
OMB No. 1545-0123
For tax year beginning and ending
Name of IC-DISC Employer identification number
Name of borrower Employer identification number
Address of borrower (number and street)
City or town, state or province, and ZIP or foreign postal code
Note: An IC-DISC may establish that the borrower has met the limitation and increased investment requirements of
sections 993(d)(2) and (3) by attaching to its return either (a) Schedule Q (Form 1120-IC-DISC), or (b) a written statement
of compliance of the borrower certified by a certified public accountant.
Under penalties of perjury, I certify that the loan
received from the above-mentioned IC-DISC qualifies
as a producer’s loan for the following reasons.
A. Limitation Rule. The amount of this loan, when added
to the unpaid balance of all of our other qualified
producer’s loans outstanding at the time this loan was
made, does not exceed:
1a. The amount of our adjusted basis (at the beginning
of our tax year in which the loan was made) in plant,
machinery, and equipment, and supporting
production facilities in the United States; plus
1b. The amount of property held primarily for sale, lease,
or rental to our customers in the ordinary course of
our trade or business at the beginning of our tax
year; plus
1c. The aggregate amount of our research and
experimental expenditures (within the meaning of
section 174) in the United States during all
preceding tax years beginning after December 31,
1971; multiplied by
2. The percentage which our receipts during the 3 tax
years immediately preceding the tax year in which
the loan was made from the sale, lease, or rental
outside the United States of property which would
be export property (determined without regard to
section 993(c)(2)(C) or (D)) if held by an IC-DISC, is
of the gross receipts during such 3 tax years from
the sale, lease, or rental of property held by us
primarily for sale, lease, or rental to our customers
in the ordinary course of our trade or business.
B. Increased Investment Requirement. The amount of
this loan, when added to the unpaid balance of all of our
producer’s loans made during our tax year, does not
exceed:
1. The amount by which the sum of the adjusted basis
of our assets described in 1a and 1b above on the
last day of the tax year during which this loan was
made exceeds the adjusted basis of those assets
on the first day of such tax year; plus
2. The aggregate amount of our research and
experimental expenditures (within the meaning of
section 174) in the United States during such tax
year.
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Date (MM/DD/YYYY)
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Signature of officer
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Type or print name and title
For Paperwork Reduction Act Notice, see the
Instructions for Form 1120-IC-DISC.
www.irs.gov/form1120icdisc
Cat. No. 11479D
Schedule Q (Form 1120-IC-DISC) (Rev. 9-2016)
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