Form 8621-A - Return By A Shareholder Making Certain Late Elections To End Treatment As A Passive Foreign Investment Company Page 2

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Form 8621-A (12-2013)

Part IV

Computation of Tax and Interest Due

9a Excess distribution. Enter amount from line 3 or 4 of Part II or line 7 or 8 of Part III

b Attach a statement that (a) shows the shareholder’s holding period for each share of stock or

block of shares held, (b) allocates the amount on line 9a to each day in the shareholder’s holding

period, and (c) aggregates all amounts that are allocated to the same taxable year.

Enter the total of the amounts determined in line 9b that are allocable to the election year and to

taxable years before the foreign corporation became a PFIC (pre-PFIC years)

Enter the shareholder’s income tax liability for the election year if the amount on line 10 above

had been included in gross income for such year .

Enter the amount of the shareholder’s income tax liability (see instructions), as reported on its

original or amended income tax return for the election year. .

Subtract line 12 from line 11

Enter the aggregate increases in tax (before credits) for each taxable year in the shareholder’s

holding period (other than the election year and pre-PFIC years) .

Foreign tax credit (see instructions)

Subtract line 15 from line 14

Determine interest on each net increase in tax determined on line 16 above in the manner

described in the instructions. Enter the aggregate amount of interest here

Add lines 13, 16, and 17 .

Determine interest on the line 18 amount in the manner described in these instructions. Enter the

aggregate amount of interest here. See instructions .

If the shareholder received an excess distribution in a prior taxable year that was not reported on a

Form 8621, the shareholder must determine the additional tax and interest due under section 1291 as a

result of such excess distribution (including the interest from the due date of the return for the taxable

year in which the excess distribution was received until the date this form is filed with the IRS). Attach a

completed Form 8621 showing the computation of the amount and enter the amount here .

Balance due. Add lines 18 through 20 .

Important: Attach to Form 8621-A a copy of the Form 8621 filed by the shareholder for any taxable year in which the shareholder received

an excess distribution from the foreign corporation.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Sign

Here

Date

Signature and Title (if any)

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid

Check

self-employed

Preparer