Form 5471
(Rev. December 2018)
Department of the Treasury
Internal Revenue Service
Information Return of U.S. Persons With Respect
to Certain Foreign Corporations
Go to www.irs.gov/Form5471 for instructions and the latest information.
Information furnished for the foreign corporation’s annual accounting period (tax year required by
section 898) (see instructions) beginning , 20 , and ending , 20
OMB No. 1545-0123
Attachment
Sequence No. 121
Name of person filing this return
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
A Identifying number
B Category of filer (See instructions. Check applicable box(es)):
1 2 3 4 5
C Enter the total percentage of the foreign corporation’s voting
stock you owned at the end of its annual accounting period
%
Filer’s tax year beginning , 20 , and ending , 20
D Check box if this is a final Form 5471 for the foreign corporation . . . . . . . . . . . . . . . . . . . . . . . . .
E Check if any excepted specified foreign financial assets are reported on this form (see instructions) . . . . . . . . . . . . . . . .
F Person(s) on whose behalf this information return is filed:
(1) Name (2) Address (3) Identifying number
(4) Check applicable box(es)
Shareholder
Officer Director
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 corporation b(1) Employer identification number, if any
b(2) Reference ID number (see instructions)
c Country under whose laws incorporated
d Date of incorporation e Principal place of business f Principal business activity
code number
g Principal business activity h Functional currency
2 Provide the following information for the foreign corporation’s accounting period stated above.
a Name, address, and identifying number of branch office or agent (if any) in the
United States
b If a U.S. income tax return was filed, enter:
(i) Taxable income or (loss)
(ii) U.S. income tax paid
(after all credits)
c Name and address of foreign corporation’s statutory or resident agent in country
of incorporation
d Name and address (including corporate department, if applicable) of person (or
persons) with custody of the books and records of the foreign corporation, and
the location of such books and records, if different
Schedule A Stock of the Foreign Corporation
(a) Description of each class of stock
(b) Number of shares issued and outstanding
(i) Beginning of annual
accounting period
(ii) End of annual
accounting period
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 49958V
Form
5471 (Rev. 12-2018)
dd mmm yyyy
Form 5471 (Rev. 12-2018)
Page 2
Schedule B Shareholders of Foreign Corporation
Part I
U.S. Shareholders of Foreign Corporation (see instructions)
(a) Name, address, and identifying
number of shareholder
(b) Description of each class of stock held by
shareholder. Note: This description should
match the corresponding description entered in
Schedule A, column (a).
(c) Number of
shares held at
beginning of annual
accounting period
(d) Number of
shares held at
end of annual
accounting period
(e) Pro rata share
of Subpart F
income (enter as a
percentage)
Part II Direct Shareholders of Foreign Corporation (see instructions)
(a) Name, address, and identifying number of
shareholder. Also include country of incorporation or
formation, if applicable.
(b) Description of each class of stock held by shareholder.
Note: This description should match the corresponding
description entered in Schedule A, column (a).
(c) Number of
shares held at
beginning of annual
accounting period
(d) Number of
shares held at
end of annual
accounting period
Form 5471 (Rev. 12-2018)
Form 5471 (Rev. 12-2018)
Page 3
Schedule C
Income Statement (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). However, if the functional currency is the U.S.
dollar, complete only the U.S. Dollars column. See instructions for special rules for DASTM corporations.
Income
DeductionsNet Income
Other
Comprehensive
Income
Functional Currency U.S. Dollars
1a Gross receipts or sales . . . . . . . . . . . . . . . . . 1a
b Returns and allowances . . . . . . . . . . . . . . . . 1b
c Subtract line 1b from line 1a . . . . . . . . . . . . . . . 1c
2 Cost of goods sold . . . . . . . . . . . . . . . . . . 2
3 Gross profit (subtract line 2 from line 1c) . . . . . . . . . . . 3
4 Dividends . . . . . . . . . . . . . . . . . . . . . 4
5 Interest . . . . . . . . . . . . . . . . . . . . . . 5
6a Gross rents . . . . . . . . . . . . . . . . . . . . 6a
b Gross royalties and license fees . . . . . . . . . . . . . . 6b
7 Net gain or (loss) on sale of capital assets. . . . . . . . . . . 7
8a Foreign currency transaction gain or loss
unrealized . . . . . . 8a
b Foreign currency transaction gain or loss
realized. . . . . . . . 8b
9 Other income (attach statement) . . . . . . . . . . . . . 9
10
Total income (add lines 3 through 9) . . . . . . . . . . . .
10
11 Compensation not deducted elsewhere . . . . . . . . . . . 11
12a Rents . . . . . . . . . . . . . . . . . . . . . . 12a
b Royalties and license fees . . . . . . . . . . . . . . . . 12b
13 Interest . . . . . . . . . . . . . . . . . . . . . . 13
14 Depreciation not deducted elsewhere . . . . . . . . . . . . 14
15 Depletion . . . . . . . . . . . . . . . . . . . . . 15
16 Taxes (exclude income tax expense (benefit)) . . . . . . . . . 16
17 Other deductions (attach statement—exclude income tax expense
(benefit)) . . . . . . . . . . . . . . . . . . . . .
17
18
Total deductions (add lines 11 through 17) . . . . . . . . . .
18
19
Net income or (loss) before unusual or infrequently occurring items, and
income tax expense (benefit) (subtract line 18 from line 10) . . . . .
19
20 Unusual or infrequently occurring items . . . . . . . . . . . 20
21a Income tax expense (benefit)
current . . . . . . . . . . . . 21a
b Income tax expense (benefit)
deferred . . . . . . . . . . . 21b
22
Current year net income or (loss) per books (combine lines 19 through 21b)
22
23a Foreign currency translation adjustments . . . . . . . . . . . 23a
b
Other . . . . . . . . . . . . . . . . . . . . . .
23b
c
Income tax expense (benefit) related to other comprehensive income . .
23c
24
Other comprehensive income (loss), net of tax (line 23a plus line 23b less
line 23c) . . . . . . . . . . . . . . . . . . . . .
24
Form 5471 (Rev. 12-2018)
Form 5471 (Rev. 12-2018)
Page 4
Schedule F Balance Sheet
Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See instructions
for an exception for DASTM corporations.
( ) ( )
( ) ( )
( ) ( )
( ) ( )
( ) ( )
Assets
(a)
Beginning of annual
accounting period
(b)
End of annual
accounting period
1 Cash . . . . . . . . . . . . . . . . . . . . . . . . . 1
2a Trade notes and accounts receivable . . . . . . . . . . . . . . . 2a
b Less allowance for bad debts . . . . . . . . . . . . . . . . . 2b
3 Derivatives . . . . . . . . . . . . . . . . . . . . . . . 3
4 Inventories . . . . . . . . . . . . . . . . . . . . . . . 4
5 Other current assets (attach statement) . . . . . . . . . . . . . . 5
6 Loans to shareholders and other related persons . . . . . . . . . . . 6
7 Investment in subsidiaries (attach statement) . . . . . . . . . . . . 7
8 Other investments (attach statement) . . . . . . . . . . . . . . . 8
9a Buildings and other depreciable assets . . . . . . . . . . . . . . 9a
b Less accumulated depreciation . . . . . . . . . . . . . . . . 9b
10a Depletable assets . . . . . . . . . . . . . . . . . . . . . 10a
b Less accumulated depletion . . . . . . . . . . . . . . . . . . 10b
11 Land (net of any amortization) . . . . . . . . . . . . . . . . . 11
12 Intangible assets:
a Goodwill . . . . . . . . . . . . . . . . . . . . . . . . 12a
b Organization costs . . . . . . . . . . . . . . . . . . . . . 12b
c Patents, trademarks, and other intangible assets . . . . . . . . . . . 12c
d Less accumulated amortization for lines 12a, 12b, and 12c . . . . . . . 12d
13 Other assets (attach statement) . . . . . . . . . . . . . . . . . 13
14 Total assets . . . . . . . . . . . . . . . . . . . . . . . 14
Liabilities and Shareholders’ Equity
15 Accounts payable . . . . . . . . . . . . . . . . . . . . . 15
16 Other current liabilities (attach statement) . . . . . . . . . . . . . 16
17 Derivatives . . . . . . . . . . . . . . . . . . . . . . . 17
18 Loans from shareholders and other related persons . . . . . . . . . . 18
19 Other liabilities (attach statement) . . . . . . . . . . . . . . . . 19
20 Capital stock:
a Preferred stock . . . . . . . . . . . . . . . . . . . . . . 20a
b Common stock . . . . . . . . . . . . . . . . . . . . . . 20b
21 Paid-in or capital surplus (attach reconciliation) . . . . . . . . . . . 21
22 Retained earnings . . . . . . . . . . . . . . . . . . . . . 22
23
Less cost of treasury stock . . . . . . . . . . . . . . . . . .
23
24 Total liabilities and shareholders equity . . . . . . . . . . . . . . 24
Schedule G Other Information
Yes No
1 During the tax year, did the foreign corporation own at least a 10% interest, directly or indirectly, in any foreign
partnership? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” see the instructions for required statement.
2 During the tax year, did the foreign corporation own an interest in any trust? . . . . . . . . . . . . . .
3
During the tax year, did the foreign corporation own any foreign entities that were disregarded as separate from its
owner under Regulations sections 301.7701-2 and 301.7701-3 or did the foreign corporation own any foreign
branch (see instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” you are generally required to attach Form 8858 for each entity or branch (see instructions).
4 a During the tax year, did the filer pay or accrue any base erosion payment under section 59A(d) to the foreign
corporation or did the filer have a base erosion tax benefit under section 59A(c)(2) with respect to a base erosion
payment made or accrued to the foreign corporation (see instructions)? . . . . . . . . . . . . . . .
If “Yes,” complete lines 4b and 4c.
b Enter the total amount of the base erosion payments . . . . . . . . . . . . . . . .
$
c Enter the total amount of the base erosion tax benefit . . . . . . . . . . . . . . . .
$
5 a During the tax year, did the foreign corporation pay or accrue any interest or royalty for which the deduction is not
allowed under section 267A? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” complete line 5b.
b Enter the total amount of the disallowed deductions (see instructions) . . . . . . . . . . .
$
Form 5471 (Rev. 12-2018)
Form 5471 (Rev. 12-2018)
Page 5
Schedule G Other Information (continued)
Yes No
6
a
Is the filer of this Form 5471 claiming a foreign-derived intangible income deduction (under section 250) with respect
to any amounts listed on Schedule M? . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” complete lines 6b, 6c, and 6d.
b
Enter the amount of gross income derived from sales, leases, exchanges, or other dispositions (but not licenses)
from transactions with the foreign corporation that the filer included in its computation of foreign-derived deduction
eligible income (FDDEI) (see instructions) . . . . . . . . . . . . . . . . . . . .
$
c
Enter the amount of gross income derived from a license of property to the foreign corporation that the filer included
in its computation of FDDEI (see instructions) . . . . . . . . . . . . . . . . . . .
$
d Enter the amount of gross income derived from services provided to the foreign corporation that the filer included in
its computation of FDDEI (see instructions) . . . . . . . . . . . . . . . . . . . .
$
7 During the tax year, was the foreign corporation a participant in any cost sharing arrangement? . . . . . . .
8 During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?
9 If the answer to question 7 is “Yes,” was the foreign corporation a participant in a cost sharing arrangement that
was in effect before January 5, 2009? . . . . . . . . . . . . . . . . . . . . . . . . . .
10 If the answer to question 7 is “Yes,” did a U.S. taxpayer make any platform contributions as defined under
Regulations section 1.482-7(c) to that cost sharing arrangement during the taxable year? . . . . . . . . .
11
If the answer to question 10 is “Yes,” enter the present value of the platform contributions in U.S. dollars
$
12 If the answer to question 10 is “Yes,” check the box for the method under Regulations section 1.482-7(g) used to
determine the price of the platform contribution transaction(s):
Comparable uncontrolled transaction method
Market capitalization method
Income method
Residual profit split method
Acquisition price method
Unspecified methods
13 From April 25, 2014, to December 31, 2017, did the foreign corporation purchase stock or securities of a
shareholder of the foreign corporation for use in a triangular reorganization (within the meaning of Regulations
section 1.358-6(b)(2))? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
a
Did the foreign corporation receive any intangible property in a prior year or the current tax year for which the U.S.
transferor is required to report a section 367(d) annual income inclusion for the taxable year? . . . . . . . .
If “Yes,” go to line 14b.
b
Enter the amount of the earnings and profits reduction pursuant to section 367(d)(2)(B) for the taxable year
$
During the tax year, did the foreign corporation pay or accrue any foreign tax that was disqualified for credit under
section 901(m)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15 During the tax year, was the foreign corporation an expatriated foreign subsidiary under Regulations section
1.7874-12(a)(9)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” see instructions and attach statement.
16 During the tax year, did the foreign corporation participate in any reportable transaction as defined in Regulations
section 1.6011-4? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” attach Form(s) 8886 if required by Regulations section 1.6011-4(c)(3)(i)(G).
17
18 During the tax year, did the foreign corporation pay or accrue foreign taxes to which section 909 applies, or treat
foreign taxes that were previously suspended under section 909 as no longer suspended? . . . . . . . . .
19 Did you answer “Yes” to any of the questions in the instructions for line 19? . . . . . . . . . . . . . .
If “Yes,” enter the corresponding code(s) from the instructions and attach statement (see instructions)
Form 5471 (Rev. 12-2018)
Form 5471 (Rev. 12-2018)
Page 6
Schedule I
Summary of Shareholder’s Income From Foreign Corporation (see instructions)
If item F on page 1 is completed, a separate Schedule I must be filed for each Category 4 or 5 filer for whom reporting is furnished on
this Form 5471. This Schedule I is being completed for:
Name of U.S. shareholder
Identifying number
1 a
Section 964(e)(4) Subpart F dividend income from the sale of stock of a lower-tier foreign corporation
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1a
b Section 245A(e)(2) Subpart F income from hybrid dividends of tiered corporations (see instructions) . 1b
c Other Subpart F income (enter the result from Worksheet A in the instructions) . . . . . . . . 1c
2 Earnings invested in U.S. property (enter the result from Worksheet B in the instructions) . . . . . 2
3 Previously excluded export trade income withdrawn from investment in export trade assets (enter the
result from Worksheet C in the instructions) . . . . . . . . . . . . . . . . . . . . 3
4 Factoring income . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
See instructions for reporting amounts on lines 1 through 4 on your income tax return.
5 Dividends received (translated at spot rate on payment date under section 989(b)(1)) . . . . . . 5
6
Exchange gain or (loss) on a distribution of previously taxed income . . . . . . . . . . .
6
Yes No
• Was any income of the foreign corporation blocked? . . . . . . . . . . . . . . . . . . . . . . .
• Did any such income become unblocked during the tax year (see section 964(b))? . . . . . . . . . . . . .
If the answer to either question is “Yes,” attach an explanation.
Form 5471 (Rev. 12-2018)
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome