Form 5471 (Rev. December 2015) Department of the Treasury Internal Revenue Service Information Return of U.S. Persons With Respect To Certain Foreign Corporations For more information about Form 5471, see www.irs.gov/form5471 Information furnished for the foreign corporation's annual accounting period (tax year required by section 898) (see instructions) beginning , 20 , and ending , 20 OMB No. 1545-0704 Attachment Sequence No. 121 Name of person filing this return Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address) City or town, state, and ZIP code Filer's tax year beginning E Person(s) on whose behalf this information return is filed: (1) Name (2) Address , 20 , and ending A Identifying number B Category of filer (See instructions. Check applicable box(es)): 1 (repealed) 2 3 4 5 % C Enter the total percentage of the foreign corporation's voting stock you owned at the end of its annual accounting period , 20 D Check if any excepted specified foreign financial assets are reported on this form (see instructions) . . . . . . . . . . . . . . . . (3) Identifying number (4) Check applicable box(es) Shareholder Officer Director Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be stated in U.S. dollars unless otherwise indicated. 1a Name and address of foreign corporation b(1) Employer identification number, if any b(2) Reference ID number (see instructions) c d Date of incorporation e Principal place of business f Principal business activity code number Country under whose laws incorporated h Functional currency g Principal business activity 2 Provide the following information for the foreign corporation's accounting period stated above. a Name, address, and identifying number of branch office or agent (if any) in the United States b If a U.S. income tax return was filed, enter: (i) Taxable income or (loss) (ii) U.S. income tax paid (after all credits) c Name and address of foreign corporation's statutory or resident agent in country of incorporation d Name and address (including corporate department, if applicable) of person (or persons) with custody of the books and records of the foreign corporation, and the location of such books and records, if different Schedule A Stock of the Foreign Corporation (b) Number of shares issued and outstanding (a) Description of each class of stock (i) Beginning of annual accounting period (ii) End of annual accounting period For Paperwork Reduction Act Notice, see instructions. Cat. No. 49958V Form 5471 (Rev. 12-2015) American LegalNet, Inc. www.FormsWorkFlow.com Form 5471 (Rev. 12-2015) Page 2 (b) Description of each class of stock held by shareholder. Note: This description should match the corresponding description entered in Schedule A, column (a). (c) Number of shares held at beginning of annual accounting period (d) Number of shares held at end of annual accounting period (e) Pro rata share of subpart F income (enter as a percentage) Schedule B U.S. Shareholders of Foreign Corporation (see instructions) (a) Name, address, and identifying number of shareholder Schedule C Income Statement (see instructions) Important: Report all information in functional currency in accordance with U.S. GAAP. Also, report each amount in U.S. dollars translated from functional currency (using GAAP translation rules). However, if the functional currency is the U.S. dollar, complete only the U.S. Dollars column. See instructions for special rules for DASTM corporations. Functional Currency U.S. Dollars Gross receipts or sales . . . . . . . . . . . . . . . . . . . Returns and allowances . . . . . . . . . . . . . . . . . . . Subtract line 1b from line 1a . . . . . . . . . . . . . . . . . Cost of goods sold . . . . . . . . . . . . . . . . . . . . Gross profit (subtract line 2 from line 1c) . . . . . . . . . . . . . Dividends . . . . . . . . . . . . . . . . . . . . . . . . Interest . . . . . . . . . . . . . . . . . . . . . . . . Gross rents . . . . . . . . . . . . . . . . . . . . . . . Gross royalties and license fees . . . . . . . . . . . . . . . . Net gain or (loss) on sale of capital assets . . . . . . . . . . . . . Other income (attach statement) . . . . . . . . . . . . . . . . Total income (add lines 3 through 8) . . . . . . . . . . . . . . . 10 Compensation not deducted elsewhere ............. 11a Rents . . . . . . . . . . . . . . . . . . . . . . . . . b Royalties and license fees . . . . . . . . . . . . . . . . . . 12 Interest . . . . . . . . . . . . . . . . . . . . . . . . 13 Depreciation not deducted elsewhere . . . . . . . . . . . . . . 14 Depletion ....................... 15 Taxes (exclude provision for income, war profits, and excess profits taxes) . . 16 Other deductions (attach statement--exclude provision for income, war profits, and excess profits taxes) . . . . . . . . . . . . . . . . . . 17 Total deductions (add lines 10 through 16) . . . . . . . . . . . . . 18 Net income or (loss) before extraordinary items, prior period adjustments, and the provision for income, war profits, and excess profits taxes (subtract line 17 from line 9) . . . . . . . . . . . . . . . . . . . . . . . . . Extraordinary items and prior period adjustments (see instructions) . . . . . . Provision for income, war profits, and excess profits taxes (see instructions) . . Current year net income or (loss) per books (combine lines 18 through 20) . . 1a b c 2 3 4 5 6a b 7 8 9 Deductions 1a 1b 1c 2 3 4 5 6a 6b 7 8 9 10 11a 11b 12 13 14 15 16 17 Net Income Income 19 20 21 18 19 20 21 Form 5471 (Rev. 12-2015) American LegalNet, Inc. www.FormsWorkFlow.com Form 5471 (Rev. 12-2015) Page 3 Schedule E Income, War Profits, and Excess Profits Taxes Paid or Accrued (see instructions) (a) Name of country or U.S. possession Amount of tax (c) Conversion rate (b) In foreign currency (d) In U.S. dollars 1 U.S. 2 3 4 5 6 7 8 Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schedule F Balance Sheet Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See instructions for an exception for DASTM corporations. Assets 1 2a b 3 4 5 6 7 8a b 9a b 10 11 a b c d 12 13 Cash . . . . . . . . . . . . . . . . Trade notes and accounts receivable . . . . . . Less allowance for bad debts . . . . . . . . Inventories . . . . . . . . . . . . . . Other current assets (attach statement) . . . . . Loans to shareholders and other related persons .