Form 8621 (Rev. December 2004) - Return By A Shareholder Of A Passive Foreign Investment Company Or Qualified Electing Fund Page 2

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Page

Form 8621 (Rev. 12-2004)

Part III

Gain or (Loss) From Mark-to-Market Election (See page 5 of instructions.)

Enter the fair market value of your PFIC stock at the end of the tax year

Enter your adjusted basis in the stock at the end of the tax year

Excess. Subtract line 6 from line 5. If a gain, stop here. Include this amount as ordinary income

on your tax return. If a loss, go to line 8

Enter any unreversed inclusions (as defined in section 1296(d)). See instructions.

Enter the smaller of line 7 or line 8. Include this amount as an ordinary loss on your tax return

Part IV

Distributions From and Dispositions of Stock of a Section 1291 Fund (See page 6 of instructions.)

Complete a separate Part IV for each excess distribution (see instructions).

10a

Enter your total distributions from the section 1291 fund during the current tax year with respect to the

10a

applicable stock. If the holding period of the stock began in the current tax year, see instructions

Enter the total 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 fund with

respect to the applicable stock for each of the 3 years preceding the current tax year (or if

10b

shorter, the portion of the shareholder’s holding period before the current tax year)

10c

Divide line 10b by 3. (See instructions if the number of preceding tax years is less than 3.)

10d

Multiply line 10c by 125% (1.25)

Subtract line 10d from line 10a. This amount, if more than zero, is the excess distribution with respect to

the applicable stock. If zero or less and you did not dispose of stock during the tax year, do not complete

the rest of Part IV. See instructions if you received more than one distribution during the current tax year.

10e

Also, see instructions for rules for reporting a nonexcess distribution on your income tax return

Enter gain or loss from the disposition of stock of a section 1291 fund or former section 1291

10f

fund. If a gain, complete line 11. If a loss, show it in brackets and do not complete line 11

11a

Attach a statement for each distribution and disposition. Show your holding period for each

share of stock or block of shares held. Allocate the excess distribution to each day in your

holding period. Add all amounts that are allocated to days in each tax year.

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

11b

amounts on your income tax return as other income

Enter the aggregate increases in tax (before credits) for each tax year in your holding period

11c

(other than the current tax year and pre-PFIC years). (See instructions.)

11d

Foreign tax credit. (See instructions.)

Subtract line 11d from line 11c. Enter this amount on your income tax return as “additional

11e

tax.” (See instructions.)

Determine interest on each net increase in tax determined on line 11e using the rates and

methods of section 6621. Enter the aggregate amount of interest here. (See instructions.)

11f

Part V

Status of Prior Year Section 1294 Elections and Termination of Section 1294 Elections

Complete a separate column for each outstanding election. Complete lines 9 and 10 only if there is a

partial ter mination of the section 1294 election.

(i)

(ii)

(iii)

(iv)

(v)

(vi)

Tax year of outstanding

election

Undistributed earnings to

which the election relates

Deferred tax

Interest accrued on deferred

tax (line 3) as of the filing date

Event terminating election

Earnings distributed or deemed

distributed during the tax year

Deferred tax due with this

return

Accrued interest due with

this return

Deferred tax outstanding after

partial termination of election

Interest accrued after partial

termination of election

8621

Form

(Rev. 12-2004)

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