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Form 8621 Information Return by a Shareholder of a Passive Foreign OMB No. 1545-1002

(Rev. December 2016) Investment Company or Qualified Electing Fund Attachment
Department of the Treasury ▶ Information about Form 8621 and its separate instructions is at www.irs.gov/form8621. Sequence No. 69
Internal Revenue Service
Name of shareholder Identifying number (see instructions)

Number, street, and room or suite no. (If a P.O. box, see instructions.) Shareholder tax year: calendar year 20 or other tax year
beginning , 20 and ending , 20 .
City or town, state, and ZIP code or country

Check type of shareholder filing the return: Individual Corporation Partnership S Corporation Nongrantor Trust Estate
Check if any Excepted Specified Foreign Financial Assets are Reported on this Form (see instructions) . . . . . . . . . . . . .
Name of passive foreign investment company (PFIC) or qualified electing fund (QEF) Employer identification number (if any)

Address (Enter number, street, city or town, and country.) Reference ID number (see instructions)

Tax year of PFIC or QEF: calendar year 20 or other tax year
beginning , 20 and
ending , 20 .
Part I Summary of Annual Information (See instructions.)
Provide the following information with respect to all shares of the PFIC held by the shareholder:
1 Description of each class of shares held by the shareholder:
Check if shares jointly owned with spouse.

2 Date shares acquired during the taxable year, if applicable:

3 Number of shares held at the end of the taxable year:

4 Value of shares held at the end of the taxable year (check the appropriate box, if applicable):
(a) $0-50,000 (b) $50,001-100,000 (c) $100,001-150,000 (d) $150,001-200,000
(e) If more than $200,000, list value:

5 Type of PFIC and amount of any excess distribution or gain treated as an excess distribution
under section 1291, inclusion under section 1293, or inclusion or deduction under section 1296:

(a) Section 1291 $
(b) Section 1293 (Qualified Electing Fund) $
(c) Section 1296 (Mark to Market) $

Part II Elections (See instructions.)
A Election To Treat the PFIC as a QEF. I, a shareholder of a PFIC, elect to treat the PFIC as a QEF. Complete lines 6a through 7c of Part III.
B Election To Extend Time For Payment of Tax.I, a shareholder of a QEF, elect to extend the time for payment of tax on the undistributed
earnings and profits of the QEF until this election is terminated. Complete lines 8a through 9c of Part III to calculate the tax that may be deferred.
Note: If any portion of line 6a or line 7a of Part III is includible under section 951, you may not make this election. Also, see sections 1294(c)
and 1294(f) and the related regulations for events that terminate this election.
C Election To Mark-to-Market PFIC Stock. I, a shareholder of a PFIC, elect to mark-to-market the PFIC stock that is marketable within the
meaning of section 1296(e). Complete Part IV.
D Deemed Sale Election.I, a shareholder on the first day of a PFIC’s first tax year as a QEF, elect to recognize gain on the deemed sale of my
interest in the PFIC. Enter gain or loss on line 15f of Part V.
E Deemed Dividend Election. I, a shareholder on the first day of a PFIC’s first tax year as a QEF that is a controlled foreign corporation (CFC),
elect to treat an amount equal to my share of the post-1986 earnings and profits of the CFC as an excess distribution. Enter this amount on
line 15e of Part V. If the excess distribution is greater than zero, also complete line 16 of Part V.
F Election To Recognize Gain on Deemed Sale of PFIC. I, a shareholder of a former PFIC or a PFIC to which section 1297(d) applies, elect to
treat as an excess distribution the gain recognized on the deemed sale of my interest in the PFIC on the last day of its last tax year as a PFIC
under section 1297(a). Enter gain on line 15f of Part V.
G Deemed Dividend Election With Respect to a Section 1297(e) PFIC. I, a shareholder of a section 1297(e) PFIC, within the meaning of
Regulations section 1.1297-3(a), elect to make a deemed dividend election with respect to the Section 1297(e) PFIC. My holding period in the
stock of the Section 1297(e) PFIC includes the CFC qualification date, as defined in Regulations section 1.1297-3(d). Enter the excess
distribution on line 15e, Part V. If the excess distribution is greater than zero, also complete line 16, Part V.
H Deemed Dividend Election With Respect to a Former PFIC. I, a shareholder of a former PFIC, within the meaning of Regulations section
1.1298-3(a), elect to make a deemed dividend election with respect to the former PFIC. My holding period in the stock of the former PFIC
includes the termination date, as defined in Regulations section 1.1298-3(d). Enter the excess distribution on line 15e, Part V. If the excess
distribution is greater than zero, also complete line 16, Part V.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 64174H Form 8621 (Rev. 12-2016)

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Form 8621 (Rev. 12-2016)                                                                                                             Page  2 
Part III Income From a Qualified Electing Fund (QEF).  All QEF shareholders complete lines 6a through 7c. If you are making  
         Election B, also complete lines 8a through 9c. (See instructions.) 
6a  Enter your pro rata share of the ordinary earnings of the QEF .     .  .     .  .   .         6a 
b   Enter the portion of line 6a that is included in income under section 951 or that 
    may be excluded under section 1293(g)        . .    . .  .  .    .  .  .     .  .   .         6b 
c   Subtract line 6b from line 6a. Enter this amount on your tax return as ordinary income .         . . . .   . .     .  6c 
7a  Enter your pro rata share of the total net capital gain of the QEF  .  .     .  .   .         7a 
b   Enter the portion of line 7a that is included in income under section 951 or that 
    may be excluded under section 1293(g)  .       .    . .  .  .    .  .  .     .  .   .         7b 
c   Subtract line 7b from line 7a. This amount is a net long-term capital gain. Enter this amount in Part II of the 
    Schedule D used for your income tax return. (See instructions.)     .  .     .  .   .       . .  . . . .   . .     .  7c 
    Complete lines 8 and 9 only if you are making a section 1294 election (Election B) for the current tax year.
8a  Add lines 6c and 7c  .     .  .   . .  .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  8a 
b   Enter the total amount of cash and the fair market value of other property distributed 
    or deemed distributed to you during the tax year of the QEF. (See instructions.)  . .         8b 
c   Enter the portion of line 8a not already included in line 8b that is attributable to shares 
    in the QEF that you disposed of, pledged, or otherwise transferred during the tax year        8c
d   Add lines 8b and 8c  .     .  .   . .  .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  8d 
e   Subtract line 8d from line 8a, and enter the difference (if zero or less, enter amount in brackets)  . .   . .     .  8e 
    Important:  If line 8e is greater than zero, and no portion of line 6a or 7a is includible in income under section 
    951, you may make Election B with respect to the amount on line 8e. 
9a  Enter the total tax for the tax year (See instructions.) .  .    .  .  .     .  .   .         9a 
b   Enter the total tax for the tax year determined without regard to the amount 
    entered on line 8e .     . .  .   . .  .     . .    . .  .  .    .  .  .     .  .   .         9b 
c   Subtract line 9b from line 9a.  This is the deferred tax, the time for payment of which is extended by 
    making Election B. See instructions    .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  9c 
Part IV  Gain or (Loss) From Mark-to-Market Election (See instructions.) 
10a Enter the fair market value of your PFIC stock at the end of the tax year  .    .   .       . .  . . . .   . .     .  10a
b   Enter your adjusted basis in the stock at the end of the tax year  .   .     .  .   .       . .  . . . .   . .     .  10b
c   Subtract line 10b from line 10a. If a gain, do not complete lines 11 and 12.  Include this amount as ordinary 
    income on your tax return. If a loss, go to line 11 . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  10c
11  Enter any unreversed inclusions (as defined in section 1296(d))     .  .     .  .   .       . .  . . . .   . .     .  11
12  Enter the loss from line 10c, but only to the extent of unreversed inclusions on line 11. Include this amount as 
    an ordinary loss on your tax return  . .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  12
13  If you sold or otherwise disposed of any section 1296 stock (see instructions) during the tax year:
a   Enter the fair market value of the stock on the date of sale or disposition     .   .       . .  . . . .   . .     .  13a
b   Enter the adjusted basis of the stock on the date of sale or disposition  .     .   .       . .  . . . .   . .     .  13b
c   Subtract line 13b from line 13a. If a gain, do not complete line 14. Include this amount as ordinary income on 
    your tax return. If a loss, go to line 14  . . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  13c 
14a Enter any unreversed inclusions (as defined in section 1296(d))     .  .     .  .   .       . .  . . . .   . .     .  14a 
b   Enter the loss from line 13c, but only to the extent of unreversed inclusions on line 14a. Include this amount as 
    an ordinary loss on your tax return. If the loss on line 13c exceeds unreversed inclusions on line 14a, complete 
    line 14c  . .        . . . .  .   . .  .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  14b 
c   Enter the amount by which the loss on line 13c exceeds unreversed inclusions on line 14a. Include this amount 
    on your tax return according to the rules generally applicable for losses provided elsewhere in the Code and 
    regulations  .       . . . .  .   . .  .     . .    . .  .  .    .  .  .     .  .   .       . .  . . . .   . .     .  14c 
    Note: See instructions in case of multiple sales or dispositions.
                                                                                                                          Form  8621  (Rev. 12-2016)

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Form 8621 (Rev. 12-2016)                                                                                                                     Page  3 
Part V      Distributions From and Dispositions of Stock of a Section 1291 Fund  (See instructions.) 
            Complete a separate Part V for each excess distribution and disposition (see instructions). 
15 a  Enter your total distributions from the section 1291 fund during the current tax year with respect to the  
      applicable stock. If the holding period of the stock began in the current tax year, see instructions . .          .       . 15a 
b     Enter the total distributions (reduced by the portions of such distributions that were excess distributions but 
      not included in income under section 1291(a)(1)(B)) made by the fund with respect to the applicable stock for 
      each of the 3 years preceding the current tax year (or if  shorter, the portion of the shareholder’s holding period 
      before the current tax year)  . . . .      . . .     . .   . . . .     . .     . . . .        . .    . .          .       . 15b 
c     Divide line 15b by 3. (See instructions if the number of preceding tax years is less than 3.) . .    . .          .       . 15c 
d     Multiply line 15c by 125% (1.25)  . .      . . .     . .   . . . .     . .     . . . .        . .    . .          .       . 15d 
e     Subtract line 15d from line 15a. This amount, if more than zero, is the excess distribution with respect to the 
      applicable stock. If there is an excess distribution, complete line 16. If zero or less and you did not dispose of 
      stock during the tax year, do not complete the rest of Part V. See instructions if you received more than one 
      distribution during the current tax year. Also, see instructions for rules for reporting a nonexcess distribution on 
      your income tax return .   .    . . .      . . .     . .   . . . .     . .     . . . .        . .    . .          .       . 15e 
f     Enter gain or loss from the disposition of stock of a section 1291 fund or former section 1291 fund. If a gain, 
      complete line 16. If a loss, show it in brackets and do not complete line 16 . . . . .        . .    . .          .       . 15f 
16 a  If there is a positive amount on line 15e or 15f (or both), attach a statement for each excess distribution and 
      disposition. Show your holding period for each share of stock or block of shares held. Allocate the excess 
      distribution or gain to each day in your holding period. Add all amounts that are allocated to days in each tax 
      year. 
b     Enter the total of the amounts determined in line 16a that are allocable to the current tax year and tax years before the 
      foreign corporation became a PFIC (pre-PFIC years). Enter these amounts on your income tax return as other income           16b 
c     Enter the aggregate increases in tax (before credits) for each tax year in your holding period (other than the 
      current tax year and pre-PFIC years). (See instructions.)  . . . .     . .     . . . .        . .    . .          .       . 16c
d     Foreign tax credit. (See instructions.)  . . . .     . .   . . . .     . .     . . . .        . .    . .          .       . 16d 
e     Subtract line 16d from line 16c. Enter this amount on your income tax return as “additional tax.” (See instructions.)  .    16e
f     Determine interest on each net increase in tax determined on line 16e using the rates and methods of section 
      6621. Enter the aggregate amount of interest here. (See instructions.) . .     . . . .        . .    . .          .       . 16f 
                                                                                                                                  Form  8621  (Rev. 12-2016)

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Form 8621 (Rev. 12-2016) Page 4
Part VI Status of Prior Year Section 1294 Elections and Termination of Section 1294 Elections
Complete a separate column for each outstanding election.
Complete lines 17 through
20 to report the status of
outstanding prior year
section 1294 elections.
(i) (ii) (iii) (iv) (v) (vi)
17 Tax year of outstanding
election . . . . . . .
18 Undistributed earnings to
which the election relates .
19 Deferred tax . . . . .
20
Interest accrued on deferred
tax (line 19) as of the filing date
Complete lines 21 through 24
only if a section 1294
election is terminated in the
current year.
21 Event terminating election .
22 Earnings distributed or
deemed distributed during the
tax year . . . . . . .
23 Deferred tax due with this
return . . . . . . .
24 Accrued interest due with this
return. . . . . . . .
Complete lines 25 and 26
only if there is a partial
termination of a section
1294 election in the current
tax year.
25 Deferred tax outstanding after
partial termination of election.
Subtract line 23 from line 19 .
26 Interest accrued after partial
termination of election.
Subtract line 24 from line 20 .
Form 8621 (Rev. 12-2016)

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