Internal Revenue Bulletin:  2006-16 

April 17, 2006 

APPENDIX E

APA ANNUAL REPORT SUMMARY FORM
The APA Annual Report Summary on the next page is a required APA Record. The APA Team Leader has supplied some of the information requested on the form. Taxpayer is to supply the remaining information requested by the form and submit the form as part of its Annual Report.
APA Annual Report SUMMARY   Department of the Treasury— Internal Revenue Service Office of Associate Chief Counsel (International) Advance Pricing Agreement Program APA no.
  Team Leader
  Economist
  Intl Examiner
  CA Analyst
     
APA Information   Taxpayer Name:
  Taxpayer EIN: NAICS:
  APA Term: Taxable years ending to .
  Original APA [ ] Renewal APA [ ]
  Annual Report due dates: , 200 for all APA Years through APA Year ending in 200; for each APA Year thereafter, on [month and day] immediately following the close of the APA Year.
  Principal foreign country(ies) involved in covered transaction(s):
  Type of APA: [ ] unilateral [ ] bilateral with
  Tested party is [ ] US [ ] foreign [ ] both
  Approximate dollar volume of covered transactions (on an annual basis) involving tangible goods and services: [ ] N/A [ ] <$50 million [ ] $50-100 million [ ] $100-250 million [ ] $250-500 million [ ] >$500 million
  APA tests on (check all that apply): [ ] annual basis [ ] multi-year basis [ ] term basis
  APA provides (check all that apply) a: [ ] range [ ] point [ ] floor only [ ] ceiling only [ ] other
  APA provides for adjustment (check all that apply) to: [ ] nearest edge [ ] median [ ] other point
     
APA Annual Report Information (to be completed by the Taxpayer)   APA date executed: , 200
  This APA Annual Report Summary is for APA Year(s) ending in 200 and was filed on , 200
  Check here [ ] if Annual Report was filed after original due date but in accordance with extension.
  Has this APA been amended or changed? [ ] yes[ ] no Effective Date:
  Has Taxpayer complied with all APA terms and conditions? [ ] yes[ ] no
  Were all the critical assumptions met? [ ] yes[ ] no
  Has a Primary Compensating Adjustment been made in any APA Year covered by this Annual Report? [ ] yes[ ] noIf yes, which year(s): 200
  Have any necessary Secondary Compensating Adjustments been made? [ ] yes[ ] no
  Did Taxpayer elect APA Revenue Procedure treatment? [ ] yes[ ] no
  Any change to the entity classification of a party to the APA? [ ] yes[ ] no
  Taxpayer notice information contained in the APA remains unchanged? [ ] yes[ ] no
  Taxpayer’s current US principal place of business: (City, State)
     
APA Annual Report Checklist of Key Contents (to be completed by the Taxpayer)   Financial analysis reflecting TPM calculations [ ] yes[ ] no  
  Financial statements showing compliance with TPM(s) [ ] yes[ ] no  
  Schedule M-1 or M-3 book-tax differences [ ] yes[ ] no  
  Current organizational chart of relevant portion of world-wide group [ ] yes[ ] no  
  Attach copy of APA [ ] yes[ ] no  
  Other APA records and documents included:    
  [The information required in the following section should be tailored to the particular case]
    [ ] yes[ ] no  
    [ ] yes[ ] no  
    [ ] yes[ ] no  
    [ ] yes[ ] no  
    [ ] yes[ ] no  
     
Contact Information   Authorized Representative Phone Number Affiliation and Address
       
 

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