Form 8819 - Dollar Election Under Section 985
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1
28819
Form
Dollar Election Under Section 985
OMB No. 1545-1189
(Rev. January 2010)
Department of the Treasury
Internal Revenue Service
Name of corporation making election
Employer identification number
Number, street, and room or suite no. (If a P.O. box, see instructions.)
Tax year for which dollar election is
effective
City or town, state, and ZIP code
1
Check the applicable box to indicate who is making the dollar election under
Regulations section 1.985-1(b)(2)(ii)(B)(2):
a
A noncontrolled section 902 corporation to elect the U.S. dollar as its (or its QBU branch’s) functional currency.
b
The majority domestic corporate shareholders of a noncontrolled section 902 corporation to elect the U.S. dollar as the
corporation’s (or the corporation’s QBU branch’s) functional currency.
2a
Name of noncontrolled section 902 corporation (do not complete if same as filer above)
b
Country of organization or creation
c
Country where the principal place of business of the noncontrolled section 902 corporation is located and country of
each of its QBU branches. Attach additional sheets if necessary.
3
Enter the information requested below (see instructions). Attach additional sheets if necessary.
(d) Percent of stock
(a) Name of shareholder
(b) Address (street number, P.O.
owned in each class
(c) Identifying number
box, city, state, and ZIP code)
Common
Preferred 1
Preferred 2
4
Enter the names, addresses, and identifying numbers of all persons that are related to the noncontrolled section 902 corporation
who are eligible QBUs (within the meaning of Regulations section 1.985-2(b)(1)) or that have a branch that is an eligible QBU.
Attach additional sheets if necessary.
Name
Address
Identifying number
5
Enter the name, address, and identifying number of every domestic corporate shareholder notified of the dollar election as
required by Regulations section 1.985-2(c)(3)(i). Attach additional sheets if necessary.
Identifying number
Name
Address
Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct, and complete.
Signature
Title (if any)
Date
8819
For Paperwork Reduction Act Notice, see page 2.
Cat. No. 10850K
Form
(Rev. 1-2010)
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