5471 Schedule I-1 Information for Global Intangible Low-Taxed Income

SCHEDULE I-1
(Form 5471)

Information for Global Intangible Low-Taxed Income
OMB No. 1545-0123

(Rev. December 2021)
Department of the Treasury
Internal Revenue Service

Attach to Form 5471.
Go to www.irs.gov/Form5471 for instructions and the latest information.
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Identifying number

Name of person filing Form 5471
Name of foreign corporation

Reference ID number (see instructions)

EIN (if any)

Separate Category (Enter code–see instructions.)

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Functional
Currency

1

Gross income (see instructions if cost of goods sold exceed gross
receipts) . . . . . . . . . . . . . . . . . . .

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Conversion
Rate

U.S. Dollars

1

2

Exclusions (see instructions if cost of goods sold exceed gross receipts)
a Effectively connected income . . . .
2a
b Subpart F income . . . . . . . .
2b
c High-tax exception income per section
954(b)(4) . . . . . . . . . . .
2c
d Related party dividends . . . . . .
2d
e Foreign oil and gas extraction income .
2e
3
Total exclusions (combine lines 2a through 2e) . . . . . .
Gross income less total exclusions (line 1 minus line 3) (see
4
instructions) . . . . . . . . . . . . . . . . . .
5
6
7
8
9a
b
c
d

Deductions properly allocable to amount on line 4 . . . . .
Tested income (loss) (line 4 minus line 5) (see instructions) . . .
Tested foreign income taxes . . . . . . . . . . . .
Qualified business asset investment (QBAI) . . . . . . . .
Interest expense included on line 5 . .
9a
Qualified interest expense . . . . .
9b
Tested loss QBAI amount . . . . .
9c
Tested interest expense (line 9a minus the sum of line 9b and line
9c). If zero or less, enter -0- . . . . . . . . . . . . .

10a Interest income included in line 4
b Qualified interest income . . .
c Tested interest income (line 10a
enter -0- . . . . . . . .

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minus
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10a
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10b
line 10b). If zero or less,
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For Paperwork Reduction Act Notice, see instructions.

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4
5
6
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9d

10c

Cat. No. 71400M

Schedule I-1 (Form 5471) (Rev. 12-2021)