Internal Revenue Bulletin:  2003-28 

July 14, 2003 

APPENDIX A

   
APPENDIX A
The election statement must set forth the following information, which may be provided in the following format:
  FOREIGN INSURANCE COMPANY ELECTION UNDER SECTION 953(d)
(1) (Name, address, principal place of business, if different, tax identification number, and place of incorporation of the electing corporation) hereby elects to be treated as a domestic corporation for U.S. tax purposes. [The electing corporation may obtain a tax identification number by filing a Form SS-4 (“Application for Employer Identification Number”) with the Philadelphia Submission Processing Center.]
(2) (Name of electing corporation) waives all benefits to (Name of electing corporation) granted by the United States under any treaty.
(3) (Name of electing corporation) agrees, (for all years in which this election is in effect), to timely file a U.S. income tax return and timely remit the income tax due on its income, determined as if (Name of electing corporation) were a domestic corporation subject to part I or part II of subchapter L, and the additional tax imposed under section 953(d)(6).
(4) Attached to this election statement is a complete list of all U.S. shareholders (within the meaning of section 953(c)(1)(A)) of (Name of electing corporation) as of a date no more than 90 days prior to the date this election statement is mailed. The list includes the name, address, and tax identification number of, and ownership percentage for, each U.S. shareholder. (Name of electing corporation) agrees to file an updated list containing the information prescribed in this paragraph determined as of the last day of each taxable year. This updated list will be filed with the U.S. tax return reporting the income earned by the electing corporation for each taxable year the election is in effect.
(5) Attached to this election statement is the Form 2848 (“Power of Attorney and Declaration of Representative”) or Form 8821 (“Tax Information Authorization”) designating a U.S. resident authorized to receive confidential tax information, including any notice of deficiency, on behalf of (Name of electing corporation). (Name of electing corporation) agrees to produce its books and records, or a true and accurate copy thereof, in the United States upon request of the Internal Revenue Service.
(6) (Name of electing corporation) maintains an office or other fixed place of business in the United States located at and owns assets which are physically located in the United States with an adjusted basis equal to 10% of the base year's gross income of (Name of electing corporation) (“Office and Asset Tests”). Attached is the Asset Calculation Sheet [see Appendix B].
  or
(6) (Name of electing corporation) is a member of a consolidated group within the meaning of Treas. Reg. § 1.1502-1(h). (Name of electing corporation) satisfies the Office and Asset Tests based on the office and assets of (Name of U.S. Affiliate) (a member of the consolidated group). (Name of U.S. Affiliate) maintains an office or fixed place of business in the United States located at and owns assets that are physically located in the United States with an adjusted basis equal to 10% of (Name of electing corporation)'s gross income for the base year. Attached are: 1) a copy of the Form 1122 (“Authorization and Consent of Subsidiary Corporation To Be Included in a Consolidated Income Tax Return”) in which the electing corporation consented to be included in the consolidated return, if such form was filed for the electing corporation; 2) a copy of the most recent Form 851 (“Affiliations Schedule”) filed by the consolidated group; 3) copies of the supporting statements attached to the most recent consolidated return, showing gross and taxable income and beginning and ending balance sheets with respect to the U.S. Affiliate upon whose office and assets the electing corporation will rely to satisfy the Office and Asset Tests; and 4) the Asset Calculation Sheet [see Appendix B].
  or
(6) (Name of electing corporation) agrees to provide security for the payment of any amounts due under the Code. The security will be in an amount and upon such terms as stated in a closing agreement to be executed between the Internal Revenue Service and (Name of electing corporation). Attached is the power of attorney, Form 2848, for the person authorized to execute a closing agreement on behalf of (Name of electing corporation).
(7) This election shall be effective as of the first day of the electing corporation's taxable year (including a short taxable year) commencing . The undersigned declares under penalty of perjury that the statements contained in this election and accompanying documents are true and complete to the best of his/her knowledge and belief.
     
Date   (Title)
    (Name of corporation)

More Internal Revenue Bulletins