Form  5452                           Corporate Report of Nondividend Distributions 
(Rev. October 2016)                                 ▶ For calendar year ending December 31,                                          OMB No. 1545-0123 
Department of the Treasury                          ▶ Attach to the corporation’s income tax return. 
Internal Revenue Service           ▶ Information about Form 5452 and its instructions is at www.irs.gov/form5452.
Name                                                                                                                 Employer identification number 

A Has the corporation filed a Form 5452 for a prior calendar year?  . .          . .     .  . .   .          . .   . .     . .  .  ▶ Yes               No

  If “Yes,” enter the applicable year(s) 

B Are any of the distributions part of a partial or complete liquidation?        . .     .  . .   .          . .   . .     . .  .  ▶ Yes               No

  If “Yes,” attach explanation. 

C  Earnings and Profits  (See Supporting                             D  Shareholders at Date of Last Dividend  
  Information in instructions.)                                           Payment 
  • Accumulated earnings and profits                                      • Number of individuals                  . .     . .  
  (since February 28, 1913) at the                                        • Number of partnerships .                 .     . .
  beginning of the tax year  .         . .    ▶ $                         • Number of corporations and other 
                                                                            shareholders          .          . .   . .     . .
  • Actual earnings and profits for the  
  current tax year  .       .    . .   . .  ▶     $ 

E  Corporate Distributions  (see instructions) 
            Total Amount Paid                       Amount Paid During Calendar Year From Earnings & Profits                 Amount Paid During  
  Date Paid       (Common (C),         Amount                    Since February 28, 1913                       Percentage    Calendar Year From    Percentage 
                      Other (O))        Share                                                                                    & Profits Since 
                  Preferred (P),         Per          From the       Accumulated            Total                  Taxable   Other Than Earnings   Nontaxable
                                                    Current Year                                                                 February 28, 1913     

            $                      $              $              $                 $                                   % $                               %

  Totals    $                                     $              $                 $                                         $
For Paperwork Reduction Act Notice, see the instructions.                          Cat. No. 11881T                              Form 5452 (Rev. 10-2016) 

Form 5452 (Rev. 10-2016)                                                                                                       Page 2 

Instructions                                                        • If the corporation was required to complete Schedule L (Form 
                                                                    1120) for the tax year, a tax basis balance sheet. Show the 
Section references are to the Internal Revenue Code, unless         application of the net differences to the balance sheet items as 
otherwise noted.                                                    shown on Schedule L. Explain any further adjustments 
Future Developments                                                 necessary to figure the balance sheet on a tax basis. If the 
                                                                    corporation used an accelerated method of depreciation, attach 
For the latest information about developments related to Form       a schedule of the depreciation (and any amortization) figured 
5452 and its instructions, such as legislation enacted after they   under the straight line method. Also attach a reconciliation of 
were published, go to www.irs.gov/form5452.                         any difference between that amount and the amount deducted 
Purpose of Form                                                     on Form 1120 or other comparable return. See Exhibits B and C 
                                                                    in Rev. Proc. 75-17. 
Complete Form 5452 if the corporation made nondividend  
distributions to shareholders under section 301, section            2.  The parent of a consolidated group must also attach the  
1368(c)(3), or section 1371(e).                                     following information. 
                                                                    • A schedule that shows the allocation of the consolidated tax 
Who Must File                                                       liability and identifies the method used. (Indicate if an  
All corporations that have made nondividend distributions to        intercompany agreement is in effect.) 
their shareholders must file Form 5452. If the corporation is a     • A schedule that shows the taxable income or loss of each  
member of a consolidated group, the parent corporation must         member of the consolidated group. 
file Form 5452.                                                     • For each member of a consolidated group that made  
An S corporation should file this form only for distributions       nondividend distributions, provide the information requested in 
made under section 1368(c)(3). However, a corporation making        item 1 above. 
cash distributions under section 1371(e) during the post-
termination transition period from being an S corporation should    E. Corporate Distributions 
file this form.                                                     Complete Part E, Corporate Distributions, showing the taxable 
                                                                    and nontaxable status of distributions reported to shareholders. 
How and When To File                                                The percentage of distributions that is taxable and the 
A calendar tax year corporation must attach Form 5452 and           percentage that is nontaxable are based on the amounts shown 
the items listed under Supporting Information to its income tax     on each line in the column labeled "Total Amount Paid." If 
return due for the tax year in which the nondividend                noncash distributions were made, attach a statement and show 
distributions were made.                                            both the tax bases and fair market values. 
A fiscal tax year corporation must attach Form 5452 and the 
items listed under Supporting Information to its income tax         Paperwork Reduction Act Notice.We ask for the information 
return due for the first fiscal year ending after the calendar year on this form to carry out the Internal Revenue laws of the United 
in which the nondividend distributions were made.                   States. You are required to give us the information. We need it 
Nondividend Distributions                                           to ensure that you are complying with these laws and to allow 
                                                                    us to figure and collect the right amount of tax.
Nondividend distributions are distributions made to  
shareholders in the normal course of business.                      You are not required to provide the information requested on 
                                                                    a form that is subject to the Paperwork Reduction Act unless 
They are considered fully or partially nontaxable as dividends      the form displays a valid OMB control number. Books or 
only because the paying corporation’s current and                   records relating to a form or its instructions must be retained as 
accumulated earnings and profits are less than the                  long as their contents may become material in the 
distributions. Nondividend distributions do not include tax-free    administration of any Internal Revenue law. Generally, tax 
stock dividends or distributions exchanged for stock in             returns and return information are confidential, as required by 
liquidations or redemptions.                                        section 6103.
Supporting Information                                              The time needed to complete and file this form will vary 
1.  Attach the following information to Form 5452. See  Rev.        depending on individual circumstances. The estimated burden 
Proc. 75-17, 1975-1 C.B. 677.                                       for business taxpayers filing this form is approved under OMB 
                                                                    control number 1545-0123 and is included in the estimates 
• A computation of earnings and profits for the tax year (see the   shown in the instructions for their business income tax return.
example of a filled-in worksheet and a blank worksheet below). 
If the corporation was required to complete Schedule M-1 (Form      If you have comments concerning the accuracy of these time 
1120) or Schedule M-3 (Form 1120) for the tax year, also attach     estimates or suggestions for making this form simpler, we would 
a schedule of the differences between the earnings and profits      be happy to hear from you. See the instructions for the tax 
computation and the Schedule M-1 or Schedule M-3.                   return with which this form is filed. 
• A year-by-year computation of the accumulated earnings and 
profits, and a schedule of differences since the origin of the 
company, February 28, 1913, or the last year that information 
was furnished, whichever is later. 

Form 5452 (Rev. 10-2016)                                                                                                                   Page 3 
             Example of a Filled-In Worksheet for Figuring Current Year Earnings and Profits 
                                                       XYZ Corporation, EIN 00-0000000 
                                                                 123 Main Street 
                                                         Anycity, Yourstate 20200 
Date Incorporated:            1/1/99                                      Retained Earnings        Earnings and Profits  Accumulated 
                                                                            Shown in Books         Current Year          Earnings and  
Method of Accounting:           Accrual                                                                                       Profits      Key 
                                                                          Debit        Credit      Debit       Credit         Credit  
                                                                                                                              Balance      
       Balance forward 12/31/          2015                                       $225,000                                    $20,900
                                Year     2016
  1    Taxable  income*  from  Form  1120,  line  28  (or  
       comparable line of other income tax return) .     .                             214,700             $214,700                        a
  2    Federal income taxes per books and tax return                      $60,000                  $60,000                                 a
  3    Excess of capital losses over capital gains (tax basis)            3,600                    3.600                                   a
  4    Depreciation  adjustment  on  earnings  and  profits  
       (section 312(k)) .     . .   .  . .   . .   .   . .                                                     24,000
  5    Depreciation adjustment on sale of property       .                                         4,000
  6    Total itemized expenses from line 5, Schedule M-1                  11,050
   a   Travel and entertainment .      . .   . .   .   . .     $200                                200                                     a
   b   Life  insurance  premium  greater  than  cash  
       surrender value (CSV) .      .  . .   . .   .   . .     9,500                               9,500                                   a
   c   Nondeductible interest paid for tax-exempt bonds        850                                 850                                     a
   d   Contributions carryover .       . .   . .   .   . .     500                                 500                                     a
   e   Other (list separately) .    .  . .   . .   .   . .    
  7    Total itemized income from line 7, Schedule M-1                                 14,500
   a   Life insurance proceeds greater than CSV .        .     6,000                                           6,000                       a
   b   Bad  debt  recovery  (not  charged  against  taxable  
       income)     .     . .  . .   .  . .   . .   .   . .     3,500                                                                       b
   c   Tax-exempt interest on municipal bonds.         . .     5,000                                           5,000                       a
   d   Other (list separately) .    .  . .   . .   .   . .    
  8    RefundSAMPLEof prior year federal income taxes .  .    
  9    Reserve for contingencies       . .   . .   .   . .                10,000                                                           c
10     Additional adjustments: 
    
11     Totals .    .     . .  . .   .  . .   . .   .   . .                                         78,650      249,700                     
Current Year Earnings and Profits        .   . .   .   . .                                                     171,050
Cash Distributions: 
Preferred stock: 3/15/2016, 6/15/2016, 9/15/2016, 12/15/2016   40,000                              40,000                                  a
10,000 Shares at $1.00/Share × 4 quarters = $40,000
Common stock:
1. 3/31/2016 - 90,000 Shares at $1.00 = $90,000
From current year earnings and profits .     . .     72.81 %   65,525                              65,525                                  a
From accumulated earnings and profits        . .     23.22 %   20,900                                                         (20,900)     a
Total distribution from earnings and profits .       96.03 %   86,425
From other distribution .     . .   .  . .   . .       3.97 %  3,575
Total distribution .     . .  . .   .  . .   . .       100   % 90,000

2. 9/30/2016 - 90,000 Shares at $1.00 = $90,000
From current year earnings and profits                 72.81%  65,525                              65,525                                  a
From other distribution                                27.19%  24,475
Total distribution                                       100%  90,000
Total cash distributions .    . .   .  . .   . .   .   . .                220,000
Totals . .   .     . .     .  . .   .  . .   . .   .   . .                304,650      229,200     171,050     171,050
Current year change .      .  . .   .  . .   . .   .   . .                75,450                                              (20,900)
Balance forward 12/31/         2016 .  . .   . .   .   . .                        $149,500                                    $—0—
Explanation of Key                                                                                                       Form 5452 (Rev. 10-2016) 
a  - Identical items on the same line. 
b  - Item offset in 2014. Bad debt reserve method used for book accounting. 
c  - Item partially offset.   
* Taxable income before net operating loss deduction and special deductions. 

Form 5452 (Rev. 10-2016)                                                                                                              Page 4 
                               Worksheet for Figuring Current Year Earnings and Profits
Date Incorporated:                                                  Retained Earnings         Earnings and Profits  Accumulated 
Method of Accounting:                                                 Shown in Books          Current Year          Earnings and  
                                                                                                                         Profits      Key 
                                                                    Debit         Credit      Debit      Credit          Credit       
                                                                                                                    Balance 
       Balance forward 12/31/
                               Year
1      Taxable  income*  from  Form  1120,  line  28  (or  
       comparable line of other income tax return) . .  
2      Federal income taxes per books and tax return 
3      Excess of capital losses over capital gains (tax basis) 
4      Depreciation  adjustment  on  earnings  and  profits  
       (section 312(k)) .    . . . . .   .   . . .   .  
5      Depreciation adjustment on sale of property   .  
6      Total itemized expenses from line 5, Schedule M-1 
a      Travel and entertainment .  . .   .   . . .   .
b      Life  insurance  premium  greater  than  cash  
       surrender value (CSV) .   . . .   .   . . .   .  
c      Nondeductible interest paid for tax-exempt bonds 
d      Contributions carryover .   . .   .   . . .   .  
e      Other (list separately) . . . .   .   . . .   .  
7      Total itemized income from line 7, Schedule M-1 
a      Life insurance proceeds greater than CSV .    .  
b      Bad  debt  recovery  (not  charged  against  taxable  
       income)  .        . . . . . . .   .   . . .   .  
c      Tax-exempt interest on municipal bonds.   .   .  
d      Other (list separately) . . . .   .   . . .   .  
8      Refund of prior year federal income taxes .   .  
9      Reserve for contingencies   . .   .   . . .   .  
10     Additional adjustments: 
 
11     Totals . .        . . . . . . .   .   . . .   .                                                                                
Current Year Earnings and Profits    .   .   . . .   .  
Cash Distributions: 

From current year earnings and profits . .   .         % 
From accumulated earnings and profits    .   .         % 
Total distribution from earnings and profits .         % 
From other distribution .    . . . . .   .   .         % 
Total distribution .     . . . . . . .   .   .   100   %

Total cash distributions .   . . . . .   .   . . .   .
Totals . . .    .        . . . . . . .   .   . . .   .
Current year change .      . . . . . .   .   . . .   .  
Balance forward 12/31/           . . .   .   . . .   .  
* Taxable income before net operating loss deduction and special deductions.                                        Form 5452 (Rev. 10-2016)