Form 8621-A - Return By A Shareholder Making Certain Late Elections To End Treatment As A Passive Foreign Investment Company Page 4

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Form 8621-A (12-2005)
Balance Sheet for Election Year
Complete this balance sheet if the shareholder is making election B or D .
Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See the
instructions for an exception for DASTM corporations.
(a)
(b)
Assets
Beginning of annual
End of annual
accounting period
accounting period
1
1
Cash
2a
2a
Trade notes and accounts receivable
(
( )
)
2b
b Less allowance for bad debts
3
3
Inventories
4
4
Other current assets (attach schedule)
5
5
Loans to shareholders and other related persons
6
6
Investment in subsidiaries (attach schedule)
7
7
Other investments (attach schedule)
8a
8a
Buildings and other depreciable assets
(
) (
)
8b
b Less accumulated depreciation
9a
9a
Depletable assets
(
( )
)
9b
b Less accumulated depletion
10
10
Land (net of any amortization)
11
Intangible assets (see instructions for required attachments):
11a
a Goodwill
11b
b
Organization costs
11c
c Patents, trademarks, and other intangible assets
(
) (
)
11d
d
Less accumulated amortization for lines 11a, b, and c
12
12
Other assets (attach schedule)
13
Total assets
13
Liabilities and Shareholders’ Equity
14
14
Accounts payable
15
15
Other current liabilities (attach schedule)
16
16
Loans from shareholders and other related persons
17
17
Other liabilities (attach schedule)
18
Capital stock:
18a
a
Preferred stock
18b
b Common stock
19
Paid-in or capital surplus (attach reconciliation)
19
20
20
Retained earnings
(
( )
)
21
21
Less cost of treasury stock
22
Total liabilities and shareholders’ equity
22
8621-A
Form
(12-2005)

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