Form 5472 (Rev. December 2011)

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5472
Information Return of a 25% Foreign-Owned U.S. Corporation or a
Foreign Corporation Engaged in a U.S. Trade or Business
Form
(Under Sections 6038A and 6038C of the Internal Revenue Code)
(Rev. December 2011)
OMB No. 1545-0805
For tax year of the reporting corporation beginning
,
, and ending
,
Department of the Treasury
Note. Enter all information in English and money items in U.S. dollars.
Internal Revenue Service
Part I
Reporting Corporation (see instructions). All reporting corporations must complete Part I.
1a Name of reporting corporation
1b Employer identification number
Number, street, and room or suite no. (if a P.O. box, see instructions)
1c Total assets
City or town, state, and ZIP code (if a foreign address, see instructions)
$
1d Principal business activity
1e Principal business activity code
▶
▶
1f Total value of gross payments made or received
1g Total number of Forms 5472
1h Total value of gross payments made or received (see
(see instructions) reported on this Form 5472
filed for the tax year
instructions) reported on all Forms 5472
$
$
1i Check here if this is a
1j Country of
1k Country(ies) under whose laws the reporting
1l Principal country(ies) where
incorporation
corporation files an income tax return as a resident
business is conducted
consolidated filing of
Form 5472
▶
2
Check here if, at any time during the tax year, any foreign person owned, directly or indirectly, at least 50% of (a) the total voting power of all
classes of the stock of the reporting corporation entitled to vote, or (b) the total value of all classes of stock of the reporting corporation
▶
Part II
25% Foreign Shareholder (see instructions)
1a Name and address of direct 25% foreign shareholder
1b U.S. identifying number, if any
1c Principal country(ies) where
1d Country of citizenship,
1e Country(ies) under whose laws the direct 25% foreign shareholder
business is conducted
organization, or incorporation
files an income tax return as a resident
2a Name and address of direct 25% foreign shareholder
2b U.S. identifying number, if any
2c Principal country(ies) where
2d Country of citizenship,
2e Country(ies) under whose laws the direct 25% foreign shareholder
business is conducted
organization, or incorporation
files an income tax return as a resident
3a Name and address of ultimate indirect 25% foreign shareholder
3b U.S. identifying number, if any
3c Principal country(ies) where
3d Country of citizenship,
3e Country(ies) under whose laws the ultimate indirect 25% foreign
business is conducted
organization, or incorporation
shareholder files an income tax return as a resident
4a Name and address of ultimate indirect 25% foreign shareholder
4b U.S. identifying number, if any
4c Principal country(ies) where
4d Country of citizenship,
4e Country(ies) under whose laws the ultimate indirect 25% foreign
business is conducted
organization, or incorporation
shareholder files an income tax return as a resident
Related Party (see instructions)
Part III
Check applicable box: Is the related party a
foreign person or
U.S. person?
All reporting corporations must complete this question and the rest of Part III.
1a Name and address of related party
1b U.S. identifying number, if any
1d Principal business activity code
▶
1c Principal business activity
▶
1e Relationship—Check boxes that apply:
Related to reporting corporation
Related to 25% foreign shareholder
25% foreign shareholder
1f Principal country(ies) where business is conducted
1g Country(ies) under whose laws the related party files an income tax return as a
resident
5472
For Paperwork Reduction Act Notice, see page 4.
Form
(Rev. 12-2011)
Cat. No. 49987Y

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