SCHEDULE O
(Form 5471)
(Rev. December 2012)
Department of the Treasury
Internal Revenue Service
Organization or Reorganization of Foreign
Corporation, and Acquisitions and
Dispositions of its Stock
Information about Schedule O (Form 5471) and its instructions is at www.irs.gov/form5471
Attach to Form 5471.
OMB No. 1545-0704
Name of person filing Form 5471 Identifying number
Name of foreign corporation EIN (if any) Reference ID number (see instructions)
Important: Complete a separate Schedule O for each foreign corporation for which information must be reported.
Part I
To Be Completed by U.S. Officers and Directors
(a)
Name of shareholder for whom
acquisition information is reported
(b)
Address of shareholder
(c)
Identifying number
of shareholder
(d)
Date of original
10% acquisition
(e)
Date of additional
10% acquisition
Part II To Be Completed by U.S. Shareholders
Note: If this return is required because one or more shareholders became U.S. persons, attach a list showing the names
of such persons and the date each became a U.S. person.
Section A—General Shareholder Information
(a)
Name, address, and identifying number of
shareholder(s) filing this schedule
(b)
For shareholder’s latest U.S. income tax return filed, indicate:
(1)
Type of return
(enter form number)
(2)
Date return filed
(3)
Internal Revenue Service Center
where filed
(c)
Date (if any) shareholder
last filed information
return under section 6046
for the foreign corporation
Section B—U.S. Persons Who Are Officers or Directors of the Foreign Corporation
(a)
Name of U.S. officer or director
(b)
Address
(c)
Social security number
(d)
Check appropriate
box(es)
Officer
Director
Section C—Acquisition of Stock
(a)
Name of shareholder(s) filing this schedule
(b)
Class of stock
acquired
(c)
Date of
acquisition
(d)
Method of
acquisition
(e)
Number of shares acquired
(1)
Directly
(2)
Indirectly
(3)
Constructively
For Paperwork Reduction Act Notice, see the Instructions for Form 5471.
Cat. No. 61200O Schedule O (Form 5471) (Rev. 12-2012)
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Schedule O (Form 5471) (Rev. 12-2012)
Page 2
(f)
Amount paid or value given
(g)
Name and address of person from whom shares were acquired
Section D—Disposition of Stock
(a)
Name of shareholder disposing of stock
(b)
Class of stock
(c)
Date of disposition
(d)
Method
of disposition
(e)
Number of shares disposed of
(1)
Directly
(2)
Indirectly
(3)
Constructively
(f)
Amount received
(g)
Name and address of person to whom disposition of stock was made
Section E—Organization or Reorganization of Foreign Corporation
(a)
Name and address of transferor
(b)
Identifying number (if any)
(c)
Date of transfer
(d)
Assets transferred to foreign corporation
(1)
Description of assets
(2)
Fair market value
(3)
Adjusted basis (if transferor was
U.S. person)
(e)
Description of assets transferred by, or notes or
securities issued by, foreign corporation
Section F—Additional Information
(a) If the foreign corporation or a predecessor U.S. corporation filed (or joined with a consolidated group in filing) a U.S. income tax return for
any of the last 3 years, attach a statement indicating the year for which a return was filed (and, if applicable, the name of the corporation filing
the consolidated return), the taxable income or loss, and the U.S. income tax paid (after all credits).
(b) List the date of any reorganization of the foreign corporation that occurred during the last 4 years while any U.S. person held 10% or
more in value or vote (directly or indirectly) of the corporation’s stock
(c) If the foreign corporation is a member of a group constituting a chain of ownership, attach a chart, for each unit of which a shareholder
owns 10% or more in value or voting power of the outstanding stock. The chart must indicate the corporation’s position in the chain of
ownership and the percentages of stock ownership (see instructions for an example).
Schedule O (Form 5471) (Rev. 12-2012)
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