Form 3520-A - Annual Information Return Of Foreign Trust With A U.s. Owner - 2004

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Annual Information Return of Foreign

3520-A

OMB No. 1545-0160

Form

Trust With a U.S. Owner

2004

(Under section 6048(b))

Department of the Treasury

Internal Revenue Service

See separate instructions.

Note: All infor mation must be in English. Show all amounts in U.S. dollars.

For calendar year 2004, or tax year beginning

, 2004, ending

, 20

Check appropriate boxes.

Initial return

Final return

Amended return

Part I

General Information (see instructions)

1a Name of foreign trust

Employer identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town

e State or province

f ZIP or postal code

Country

Did the foreign trust appoint a U.S. agent (defined on page 2 of the instructions) who can provide the IRS with all

Yes

relevant trust information?

If “Yes,” skip lines 2a through 2e and go to line 3.

If “No,” you are required to attach a copy of all trust documents as indicated below. If these documents have been attached to a Form

3520-A filed within the previous 3 years, attach only relevant updates.

Attached

Year

Have you attached a copy of:

Yes

Previously

Attached

a Summary of all written and oral agreements and understandings relating to the trust?

b The trust instrument?

c Memoranda or letters of wishes?

d Subsequent variances to original trust documents?

e Other trust documents?

3a Name of U.S. agent

Identification number

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town

e State or province

f ZIP or postal code

Country

4a Name of trustee

Identification number, if any

c Number, street, and room or suite no. (if a P.O. box, see instructions)

d City or town

e State or province

f ZIP or postal code

Country

Did the trust transfer any property (including cash) to another person (see instructions for definition) during the tax

Yes

year? If “Yes,” attach statement (see instructions).

Enter the number of Foreign Grantor Trust Owner Statements (page 3) included with this Form 3520-A

Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge

and belief, it is true, correct, and complete.

Trustee’s

Signature

Title

Date

Preparer’s

Signature

Preparer’s SSN or PTIN

Date

3520-A

For Privacy Act and Paperwork Reduction Act Notice, see page 4 of instructions.

Cat. No. 19595G