Form 5471 - Information Return Of U.s. Persons With Respect To Certain Foreign Corporations Page 4

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4
Form 5471 (Rev. 12-2012)
Page
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?
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If “Yes,” see the instructions for required statement.
2 During the tax year, did the foreign corporation own an interest in any trust?
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3 During the tax year, did the foreign corporation own any foreign entities that were disregarded as entities separate
from their owners under Regulations sections 301.7701-2 and 301.7701-3 (see instructions)? .
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If “Yes,” you are generally required to attach Form 8858 for each entity (see instructions).
4 During the tax year, was the foreign corporation a participant in any cost sharing arrangement? .
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5 During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?
6 During the tax year, did the foreign corporation participate in any reportable transaction as defined in Regulations
section 1.6011-4?
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If “Yes,” attach Form(s) 8886 if required by Regulations section 1.6011-4(c)(3)(i)(G).
7 During the tax year, did the foreign corporation pay or accrue any foreign tax that was disqualified for credit under
section 901(m)?
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8 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?
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Schedule H
Current Earnings and Profits (see instructions)
Important: Enter the amounts on lines 1 through 5c in functional currency.
1
1
Current year net income or (loss) per foreign books of account
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2
Net adjustments made to line 1 to determine current earnings and
Net
Net
profits according to U.S. financial and tax accounting standards
Additions
Subtractions
(see instructions):
a Capital gains or losses
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b Depreciation and amortization .
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c Depletion .
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d Investment or incentive allowance .
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e Charges to statutory reserves .
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f
Inventory adjustments .
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g Taxes .
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h Other (attach statement) .
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3
Total net additions .
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4
Total net subtractions .
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5 a Current earnings and profits (line 1 plus line 3 minus line 4)
5a
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b DASTM gain or (loss) for foreign corporations that use DASTM (see instructions)
5b
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c Combine lines 5a and 5b .
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5c
d Current earnings and profits in U.S. dollars (line 5c translated at the appropriate exchange rate as
defined in section 989(b) and the related regulations (see instructions))
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5d
Enter exchange rate used for line 5d
Schedule I
Summary of Shareholder’s Income From Foreign Corporation (see instructions)
If item D 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
1
Subpart F income (line 38b, Worksheet A in the instructions) .
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2
2
Earnings invested in U.S. property (line 17, Worksheet B in the instructions) .
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3
Previously excluded subpart F income withdrawn from qualified investments (line 6b, Worksheet C in the instructions)
3
4
Previously excluded export trade income withdrawn from investment in export trade assets (line 7b,
Worksheet D in the instructions)
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4
5
Factoring income .
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5
6
6
Total of lines 1 through 5. Enter here and on your income tax return. See instructions .
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7
Dividends received (translated at spot rate on payment date under section 989(b)(1)) .
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7
8
Exchange gain or (loss) on a distribution of previously taxed income
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8
Yes No
• Was any income of the foreign corporation blocked?
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• Did any such income become unblocked during the tax year (see section 964(b))?
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If the answer to either question is “Yes,” attach an explanation.
5471
Form
(Rev. 12-2012)

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