| APA Annual
Report SUMMARY |
|
Department
of the Treasury— Internal Revenue Service Office of Associate Chief
Counsel (International) Advance Pricing Agreement Program |
APA no. |
| |
Team Leader |
| |
Economist |
| |
Intl Examiner |
| |
CA Analyst |
| |
|
|
| APA Information |
|
Taxpayer Name: |
| |
Taxpayer EIN: NAICS: |
| |
APA Term: Taxable years ending
to .
|
| |
Original APA [ ] Renewal
APA [ ]
|
| |
Annual Report due dates: ,
200 for all APA Years through APA Year ending in 200; for each APA Year thereafter,
on [month and day] immediately following the close of the APA Year.
|
| |
Principal foreign country(ies)
involved in covered transaction(s):
|
| |
Type of APA: [ ] unilateral
[ ] bilateral with
|
| |
Tested party is [ ] US [
] foreign [ ] both
|
| |
Approximate dollar volume of
covered transactions (on an annual basis) involving tangible goods and services:
[ ] N/A [ ] <$50 million [ ] $50-100 million [ ] $100-250 million
[ ] $250-500 million [ ] >$500 million
|
| |
APA tests on (check all that
apply): [ ] annual basis [ ] multi-year basis [ ] term basis
|
| |
APA provides (check all that
apply) a: [ ] range [ ] point [ ] floor only [ ] ceiling only [ ]
other
|
| |
APA provides for
adjustment (check all that apply) to: [ ] nearest edge [ ] median [
] other point
|
| |
|
|
| APA Annual
Report Information (to be completed by the Taxpayer)
|
|
APA date executed: , 200 |
| |
This APA Annual Report Summary
is for APA Year(s) ending in 200 and was filed on , 200
|
| |
Check here [ ] if Annual Report
was filed after original due date but in accordance with extension.
|
| |
Has this APA been amended or
changed? [ ] yes[ ] no Effective Date:
|
| |
Has Taxpayer complied with
all APA terms and conditions? [ ] yes[ ] no
|
| |
Were all the critical assumptions
met? [ ] yes[ ] no
|
| |
Has a Primary Compensating
Adjustment been made in any APA Year covered by this Annual Report? [ ] yes[
] noIf yes, which year(s): 200
|
| |
Have any necessary Secondary
Compensating Adjustments been made? [ ] yes[ ] no
|
| |
Did Taxpayer elect APA Revenue
Procedure treatment? [ ] yes[ ] no
|
| |
Any change to the entity classification
of a party to the APA? [ ] yes[ ] no
|
| |
Taxpayer notice information
contained in the APA remains unchanged? [ ] yes[ ] no
|
| |
Taxpayer’s
current US principal place of business: (City, State)
|
| |
|
|
| APA Annual
Report Checklist of Key Contents (to be completed by the Taxpayer)
|
|
Financial analysis reflecting TPM calculations |
[ ] yes[ ] no |
|
| |
Financial statements showing compliance
with TPM(s)
|
[ ] yes[ ] no |
|
| |
Schedule M-1 or M-3 book-tax differences |
[ ] yes[ ] no |
|
| |
Current organizational chart of relevant
portion of world-wide group
|
[ ] yes[ ] no |
|
| |
Attach copy of APA |
[ ] yes[ ] no |
|
| |
Other APA records and documents included: |
|
|
| |
[The
information required in the following section should be tailored to the particular
case] |
| |
|
[ ] yes[ ] no |
|
| |
|
[ ] yes[ ] no |
|
| |
|
[ ] yes[ ] no |
|
| |
|
[ ] yes[ ] no |
|
| |
|
[ ] yes[ ] no |
|
| |
|
|
| Contact Information |
|
Authorized Representative |
Phone Number |
Affiliation and
Address
|
| |
|
|
|
| |
