OMB No. 1545-0216 
                                              International Boycott Report 
Form  5713                                                                                                              Attachment  
(Rev. December 2010)              For tax year beginning                                              , 20          ,   Sequence No. 123 
                                                                                                                        Paper filers must file in 
Department of the Treasury        and ending                                                          , 20          .   duplicate (see When and Where 
Internal Revenue Service                                 ▶ Controlled groups, see instructions.                         to File in the instructions)
Name                                                                                                          Identifying number 

Number, street, and room or suite no. If a P.O. box, see instructions. 

City or town, state, and ZIP code 

Address of service center where your tax return is filed 

Type of filer (check one): 
      Individual                      Partnership                        Corporation          Trust           Estate                Other 
1     Individuals—Enter adjusted gross income from your tax return (see instructions) 
2     Partnerships and corporations: 
a     Partnerships—Enter each partner’s name and identifying number. 
b     Corporations—Enter the name and employer identification number of each member of the controlled group (as defined in  
      section 993(a)(3)). Do not list members included in the consolidated return; instead, attach a copy of Form 851. List all  other 
      members of the controlled group not included in the consolidated return.   
      If you list any corporations below or if you attach Form 851, you must designate a common tax year. Enter on line  4b 
      the name and employer identification number of the corporation whose tax year is designated. 
                                                           Name                                               Identifying number 

      If more space is needed, attach additional sheets and check this box  .                 .  .  . . .   . .     . . . .     . .   . .  .  ▶
                                                                                                      Code                Description 
c     Enter principal business activity code and description (see instructions) 
d     IC-DISCs—Enter principal product or service code and description (see instructions) 
3     Partnerships—Each partnership filing Form 5713 must give the following information: 
a     Partnership’s total assets (see instructions) .                  . . . . .     . . .  . .  .  . . .
b     Partnership’s ordinary income (see instructions)  .                  . . .     . . .  . .  .  . . .
4     Corporations—Each corporation filing Form 5713 must give the following information: 
a     Type of form filed (Form 1120, 1120-FSC, 1120-IC-DISC, 1120-L, 1120-PC, etc.)                 . . .
b     Common tax year election (see instructions) 
      (1) Name of corporation   ▶
      (2) Employer identification number                 . . .         . . . . .     . . .  . .  .  . . .
      (3) Common tax year beginning                                                    , 20   , and ending                            , 20                . 
c     Corporations filing this form enter: 
      (1) Total assets (see instructions)  .             . . .         . . . . .     . . .  . .  .  . . .
      (2) Taxable income before net operating loss and special deductions (see instructions) .          .

5     Estates or trusts—Enter total income (Form 1041, page 1)  .                      . .  . .  .  . . .
6     Enter the total amount (before reduction for boycott participation or cooperation) of the following tax benefits (see instructions): 
a     Foreign tax credit  .           . . . . .          . . .         . . . . .     . . .  . .  .  . . .
b     Deferral of earnings of controlled foreign corporations  .               .     . . .  . .  .  . . .
c     Deferral of IC-DISC income  .         . .          . . .         . . . . .     . . .  . .  .  . . .
d     FSC exempt foreign trade income  .                 . . .         . . . . .     . . .  . .  .  . . .
e     Foreign trade income qualifying for the extraterritorial income exclusion  .               .  . . .  
Please    Under penalties of perjury, I declare that I have examined this report, including accompanying schedules and statements, and to the best of my  
          knowledge and belief, it is true, correct, and complete. 
Sign      ▲                                                                                                ▲

Here                        Signature                                                       Date            Title 
For Paperwork Reduction Act Notice, see separate instructions.                                      Cat. No. 12030E       Form  5713  (Rev. 12-2010) 

Form 5713 (Rev. 12-2010)                                                                                                               Page  2 
7 a Are you a U.S. shareholder (as defined in section 951(b)) of any foreign corporation (including a FSC that does not             Yes  No 
    use the administrative pricing rules) that had operations reportable under section 999(a)?  .    .   .      . . .   . .  
b   If the answer to question 7a is “Yes,” is any foreign corporation a controlled foreign corporation (as defined in 
    section 957(a))? .       . . . . . . .    .  .  . .   .    .  . . .    . . .    . .   .  .  . .  .   .      . . .   . .
c   Do you own any stock of an IC-DISC?  .       .  . .   .    .  . . .    . . .    . .   .  .  . .  .   .      . . .   . .
d   Do you claim any foreign tax credit?  .   .  .  . .   .    .  . . .    . . .    . .   .  .  . .  .   .      . . .   . .
e   Do you control (within the meaning of section 304(c)) any corporation (other than a corporation included in this 
    report) that has operations reportable under section 999(a)?  .   .    . . .    . .   .  .  . .  .   .      . . .   . .  
    If “Yes,” did that corporation participate in or cooperate with an international boycott at any time during its tax 
    year that ends with or within your tax year?    . .   .    .  . .  .   . . .    . .   .  .  . .  .   .      . . .   . .  
f   Are  you  controlled  (within  the  meaning  of  section  304(c))  by  any  person  (other  than  a  person  included  in  this 
    report) who has operations reportable under section 999(a)?  .    .    . . .    . .   .  .  . .  .   .      . . .   . .  
    If “Yes,” did that person participate in or cooperate with an international boycott at any time during its tax year 
    that ends with or within your tax year?  .   .  . .   .    .  . .  .   . . .    . .   .  .  . .  .   .      . . .   . .
g   Are you treated under section 671 as the owner of a trust that has reportable operations under section 999(a)?  .  
h   Are you a partner in a partnership that has reportable operations under section 999(a)?  .    .  .   .      . . .   . .  
i   Are you a foreign sales corporation (FSC) (as defined in section 922(a), as in effect before its repeal)?  .    .   . .
j   Are you excluding extraterritorial income (defined in section 114(e), as in effect before its repeal) from  
    gross income?  .         . . . . . . .    .  .  . .   .    .  . . .    . . .    . .   .  .  . .  .   .      . . .   . .
Part I   Operations in or Related to a Boycotting Country  (see instructions) 
8   Boycott of Israel—Did you have any operations in or related to any country (or with the government, a company,                  Yes  No 
    or a national of that country) associated in carrying out the boycott of Israel which is on the list maintained by the 
    Secretary of the Treasury under section 999(a)(3)? (See Boycotting Countries  in the instructions.)  .        . .   . .
    If “Yes,” complete the following table. If more space is needed, attach additional sheets using the exact format and check 
    this box   .         . . . . . . . . .    .  .  . .   .    .  . . .    . . .    . .   .  .  . .  .   .      . . .   . .  .      . ▶
       Name of country                 Identifying number of                        Principal business activity                     IC-DISCs   
                                                                                                                                    only—Enter  
                                       person having operations       Code                      Description                         product code  
         (1)                                    (2)                    (3)                           (4)                               (5) 

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                                                                                                                  Form  5713  (Rev. 12-2010) 

Form 5713 (Rev. 12-2010)                                                                                                                 Page  3 
                                                                                                                                      Yes  No 
9     Nonlisted countries boycotting Israel— Did you have operations in any nonlisted country which you know or  
      have reason to know requires participation in or cooperation with an international boycott directed against Israel? 
      If “Yes,” complete the following table. If more space is needed, attach additional sheets using the exact format and check 
      this box  .        . . . . .  . . . . . .       . . .     .  . . .    . . . . . .   . . . .  .          . . .   .       .  .    .  ▶
      Name of country                   Identifying number of                     Principal business activity                         IC-DISCs   
                                                                                                                                      only—Enter  
                                        person having operations       Code                 Description                               product code  
      (1)                                     (2)                       (3)                    (4)                                        (5) 

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                                                                                                                                      Yes  No 
10    Boycotts  other  than  the  boycott  of  Israel—Did  you  have  operations  in  any  other  country  which  you  know  or  have 
      reason to know requires participation in or cooperation with an international boycott other than the boycott of Israel? 
      If “Yes,” complete the following table. If more space is needed, attach additional sheets using the exact format and check 
      this box  .        . . . . .  . . . . . .       . . .     .  . . .    . . . . . .   . . . .  .          . . .   .       .  .    .  ▶
      Name of country                   Identifying number of                     Principal business activity                         IC-DISCs   
                                                                                                                                      only—Enter  
                                        person having operations       Code                 Description                               product code  
      (1)                                     (2)                       (3)                    (4)                                        (5) 

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                                                                                                                                      Yes  No 
11    Were you requested to participate in or cooperate with an international boycott?  . . . . .  .          . . .   .       .  
      If “Yes,” attach a copy (in English) of any and all such requests received during your tax year. If the request was in 
      a form other than a written request, attach a separate sheet explaining the nature and form of any and all such 
      requests. (See instructions.) 
12    Did you participate in or cooperate with an international boycott?  .   . . . . .   . . . .  .          . . .   .       .
      If “Yes,” attach a copy (in English) of any and all boycott clauses agreed to, and attach a general statement of the agreement.  
      If the agreement was in a form other than a written agreement, attach a separate sheet explaining the nature and form of  any 
      and all such agreements. (See instructions.)
Note:  If the answer to either question 11 or 12 is “Yes,” you must complete the rest of Form 5713. If you answered “Yes” to question  
12, you must complete Schedules A and C or B and C (Form 5713). 
                                                                                                                Form  5713  (Rev. 12-2010) 

Form 5713 (Rev. 12-2010)                                                                                                             Page  4 
Part II  Requests for and Acts of Participation in or Cooperation With an International                                Requests  Agreements 
         Boycott                                                                                                       Yes  No  Yes  No 
13 a Did you receive requests to enter into, or did you enter into, any agreement (see instructions): 
     (1) As a condition of doing business directly or indirectly within a country or with the government, a 
         company, or a national of a country to— 
         (a) Refrain  from  doing  business  with  or  in  a  country  which  is  the  object  of  an  international 
             boycott or with the government, companies, or nationals of that country? 
         (b) Refrain from doing business with any U.S. person engaged in trade in a country which is  the
             object of an international boycott or with the government, companies, or nationals of  that 
             country?     . . . . . .  .   .         . . .   . . . . . .   .            . . . . .     . . .   .
         (c) Refrain from doing business with any company whose ownership or management is made up, in 
             whole or in part, of individuals of a particular nationality, race, or religion, or to remove (or refrain 
             from selecting) corporate directors who are individuals of a particular nationality, race, or religion? 
         (d) Refrain from employing individuals of a particular nationality, race, or religion? 
     (2) As a condition of the sale of a product to the government, a company, or a national of a country,  
         to refrain from shipping or insuring products on a carrier owned, leased, or operated by a person  
         who does not participate in or cooperate with an international boycott?          . . . .     . . .   .  
b  Requests and agreements—if the answer to any part of 13a is “Yes,” complete the following table. If more space is 
     needed, attach additional sheets using the exact format and check this box  .        . . . .     . . .   . .      .   . . .   . ▶
        Name of country       Identifying number of         Principal business activity     IC-DISCs    Type of cooperation or participation 
                              person receiving the                                            only—     Number of requests   Number of agreements 
                              request or having the                                           Enter  
                                agreement              Code        Description              product     Total        Code    Total    Code 
             (1)                   (2)                  (3)            (4)                  code  (5)     (6)          (7)     (8)    (9) 

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                                                                                                                     Form  5713  (Rev. 12-2010)