
SCHEDULE O (Form 5471) 
Organization or Reorganization of Foreign Corporation, and Acquisitions and Dispositions of its Stock
(Rev. December 2012)

Cat. No. 36930T

Department of the Treasury
Internal Revenue Service

In 1 File
Print pages 1-2

Provided by the IRS AMC
(Alternative Media Center)
2013

Contents

Section:  Page
SCHEDULE O (Form 5471):  1

This electronic edition contains the entire text of the print edition.

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SCHEDULE O (Form 5471)
Organization or Reorganization of Foreign Corporation, and Acquisitions and Dispositions of its Stock
(Rev. December 2012)

Information about Schedule O (Form 5471) and its instructions is at www.irs.gov/form5471.

Attach to Form 5471.

Name of person filing Form 5471: ----
Identifying number: ----
Name of foreign corporation: ----
EIN (if any): ----
Reference ID number (see instructions): ----

Important: Complete a separate Schedule O for each foreign corporation for which information must be reported.

Part I. To Be Completed by U.S. Officers and Directors

Note: In this table, columns follow each other in this order: (a) Name of shareholder for whom acquisition information is reported: (b) Address of shareholder; (c) Identifying number of shareholder; (d) Date of original 10% acquisition; (e) Date of additional 10% acquisition
(a) ----: (b) ----; (c) ----; (d) ----; (e) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e) ----

Part II. To Be Completed by U.S. Shareholders

Note: If this return is required because one or more shareholders became U.S. persons, attach a list showing the names of such persons and the date each became a U.S. person.

Section A--General Shareholder Information

Note: In this table, columns follow each other in this order: (a) Name, address, and identifying number of shareholder(s) filing this schedule: (b) For shareholder's latest U.S. income tax return filed, indicate--(1) Type of return (enter form number), (2) Date return filed, (3) Internal Revenue Service Center where filed; (c) Date (if any) shareholder last filed information return under section 6046 for the foreign corporation
(a) ----: (b)(1) ----, (b)(2) ----, (b)(3) ----; (c) ----
(a) ----: (b)(1) ----, (b)(2) ----, (b)(3) ----; (c) ----
(a) ----: (b)(1) ----, (b)(2) ----, (b)(3) ----; (c) ----

Section B--U.S. Persons Who Are Officers or Directors of the Foreign Corporation

Note: In this table, columns follow each other in this order: (a) Name of U.S. officer or director: (b) Address; (c) Social security number; (d) Check appropriate box(es)--Officer, Director
(a) ----: (b) ----; (c) ----; (d) --, --
(a) ----: (b) ----; (c) ----; (d) --, --
(a) ----: (b) ----; (c) ----; (d) --, --

Section C--Acquisition of Stock

Note: In this table, columns follow each other in this order: (a) Name of shareholder(s) filing this schedule: (b) Class of stock acquired; (c) Date of acquisition; (d) Method of acquisition; (e) Number of shares acquired--(1) Directly, (2) Indirectly, (3) Constructively
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----

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Note: In this table, columns follow each other in this order: (f) Amount paid or value given: (g) Name and address of person from whom shares were acquired
(f) ----: (g) ----
(f) ----: (g) ----
(f) ----: (g) ----

Section D--Disposition of Stock

Note: In this table, columns follow each other in this order: (a) Name of shareholder disposing of stock: (b) Class of stock; (c) Date of disposition; (d) Method of disposition; (e) Number of shares disposed of--(1) Directly, (2) Indirectly, (3) Constructively; (f) Amount received; (g) Name and address of person to whom disposition of stock was made
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----; (f) ----; (g) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----; (f) ----; (g) ----
(a) ----: (b) ----; (c) ----; (d) ----; (e)(1) ----, (e)(2) ----, (e)(3) ----; (f) ----; (g) ----

Section E--Organization or Reorganization of Foreign Corporation

Note: In this table, columns follow each other in this order: (a) Name and address of transferor: (b) Identifying number (if any); (c) Date of transfer; (d) Assets transferred to foreign corporation--(1) Description of assets, (2) Fair market value, (3) Adjusted basis (if transferor was U.S. person); (e) Description of assets transferred by, or notes or securities issued by, foreign corporation
(a) ----: (b) ----; (c) ----; (d)(1) ----, (d)(2) ----, (d)(3) ----; (e) ----
(a) ----: (b) ----; (c) ----; (d)(1) ----, (d)(2) ----, (d)(3) ----; (e) ----
(a) ----: (b) ----; (c) ----; (d)(1) ----, (d)(2) ----, (d)(3) ----; (e) ----

Section F--Additional Information
(a) If the foreign corporation or a predecessor U.S. corporation filed (or joined with a consolidated group in filing) a U.S. income tax return for any of the last 3 years, attach a statement indicating the year for which a return was filed (and, if applicable, the name of the corporation filing the consolidated return), the taxable income or loss, and the U.S. income tax paid (after all credits).
(b) List the date of any reorganization of the foreign corporation that occurred during the last 4 years while any U.S. person held 10% or more in value or vote (directly or indirectly) of the corporation's stock: ----
(c) If the foreign corporation is a member of a group constituting a chain of ownership, attach a chart, for each unit of which a shareholder owns 10% or more in value or voting power of the outstanding stock. The chart must indicate the corporation's position in the chain of ownership and the percentages of stock ownership (see instructions for an example).

End of SCHEDULE O (Form 5471)
