Form 5471 - Information Return Of U.s. Persons With Respect To Certain Foreign Corporations Page 2

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2
Form 5471 (Rev. 12-2012)
Page
Schedule B
U.S. Shareholders of Foreign Corporation (see instructions)
(b) Description of each class of stock held by
(c) Number of
(d) Number of
(e) Pro rata share
(a) Name, address, and identifying
shareholder. Note: This description should
shares held at
shares held at
of subpart F
number of shareholder
match the corresponding description entered in
beginning of annual
end of annual
income (enter as a
accounting period
accounting period
percentage)
Schedule A, column (a).
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.
Functional Currency
U.S. Dollars
1a Gross receipts or sales .
1a
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b Returns and allowances .
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1b
c Subtract line 1b from line 1a
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1c
2
2
Cost of goods sold
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3
3
Gross profit (subtract line 2 from line 1c)
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4
Dividends .
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4
5
Interest
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5
6 a Gross rents .
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b Gross royalties and license fees .
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6b
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Net gain or (loss) on sale of capital assets .
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7
8
8
Other income (attach statement) .
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9
Total income (add lines 3 through 8) .
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9
10
Compensation not deducted elsewhere
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10
11a Rents .
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b Royalties and license fees .
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11b
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Interest
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12
13
Depreciation not deducted elsewhere
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13
14
14
Depletion
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15
Taxes (exclude provision for income, war profits, and excess profits taxes) .
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15
16
Other deductions (attach statement—exclude provision for income, war profits,
16
and excess profits taxes)
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17
Total deductions (add lines 10 through 16) .
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17
18
Net income or (loss) before extraordinary items, prior period adjustments, and
the provision for income, war profits, and excess profits taxes (subtract line 17
from line 9) .
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18
19
Extraordinary items and prior period adjustments (see instructions) . . . . . .
19
20
20
Provision for income, war profits, and excess profits taxes (see instructions) .
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21
Current year net income or (loss) per books (combine lines 18 through 20) .
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21
5471
Form
(Rev. 12-2012)

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