Form 8858 - Information Return Of U.s. Persons With Respect To Foreign Disregarded Entities

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8858

Information Return of U.S. Persons With Respect

OMB No. 1545-1910

To Foreign Disregarded Entities

Form

Information about Form 8858 and its separate instructions is at

(Rev. December 2013)

▶

Information furnished for the foreign disregarded entity’s annual accounting period (see

Attachment

Department of the Treasury

140

Sequence No

, 20

, and ending

, 20

instructions) beginning

Internal Revenue Service

Name of person filing this return

Filer’s identifying number

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

, 20

, and ending

, 20

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 disregarded entity

b(1) U.S. identifying number, if any

b(2) Reference ID number (see instructions)

c Country(ies) under whose laws organized and entity type under local tax law

d Date(s) of organization

e Effective date as foreign

disregarded entity

f If benefits under a U.S. tax treaty were claimed with respect to

g Country in which principal business

h Principal business

i Functional currency

income of the foreign disregarded entity, enter the treaty and

activity is conducted

activity

article number

Provide the following information for the foreign disregarded entity’s accounting period stated above.

a Name, address, and identifying number of branch office or agent (if any) in

b Name and address (including corporate department, if applicable) of person(s)

with custody of the books and records of the foreign disregarded entity, and

the United States

the location of such books and records, if different

For the tax owner of the foreign disregarded entity (if different from the filer) provide the following (see instructions):

a Name and address

b Annual accounting period covered by the return (see instructions)

c(1) U.S. identifying number, if any

c(2) Reference ID number (see instructions)

d Country under whose laws organized

e Functional currency

For the direct owner of the foreign disregarded entity (if different from the tax owner) provide the following (see instructions):

a Name and address

b Country under whose laws organized

c U.S. identifying number, if any

d Functional currency

Attach an organizational chart that identifies the name, placement, percentage of ownership, tax classification, and country of organization of all entities in the chain of

ownership between the tax owner and the foreign disregarded entity, and the chain of ownership between the foreign disregarded entity and each entity in which the

foreign disregarded entity has a 10% or more direct or indirect interest. See instructions.

8858

For Paperwork Reduction Act Notice, see the separate instructions.

Form

(Rev. 12-2013)

Cat. No. 21457L