13982-A Foreign Asset Disclosure Initiative 30 Day Information R

Department of the Treasury — Internal Revenue Service

Form

13982-A

(November 2008)

Note

Foreign Asset Disclosure Initiative
30 Day Information Request

OMB No. XXXX-XXXX

You must provide all of the information requested below within 30 days of the receipt of your preliminary eligibility letter.
Your continued participation in the initiative will be dependent on your compliance with the requirements of Revenue
Procedure 2008-68

Taxpayer Data

Section I

1. Taxpayer name(s) (Include middle initial(s) and name of spouse if joint return)

2. Taxpayer Identification Number (EIN or SSN)

3. Street Address (No P.O. Boxes. Include taxpayer's residence address, City,
State, and ZIP Code)

4. Spouse's SSN (if joint return)
5. Daytime telephone number

(

)

6. Do you have a power of attorney? (If yes, attach a copy to this request)

Section II

Yes

No

Facts Relating to Foreign Accounts/Entities, Promoters, Facilitators, and Advisors

7. List the name, firm or financial institution affiliation, address, and telephone number of all parties who organized, managed,
promoted, solicited, or in any way facilitated the taxpayer's involvement in the foreign accounts and/or entities.
Name

Firm or Financial
Institution

Address

8. Do you have any promotional materials, transactional materials, or other related correspondence or
documentation regarding the establishment of the accounts and entities described in Questions 14
and 15 below?

Telephone

Yes

No

9. List the name, firm, address, and telephone number of all professionals who advised the taxpayer with regard to his or her
participation in the foreign accounts and/or entities.
Name

Firm

Address

Telephone

10. List all foreign financial accounts owned by or held for the benefit of the taxpayer at any time after 12/31/2001. Include the financial
institution name, address and type of account.
Name

Catalog Number 52524P

Address

www.irs.gov

Type of Account

Form 13982-A (Rev. 11-2008)

Page 2 of 2

Section II

Facts About Foreign Accounts/Entities, Promoters, Facilitators, and Advisors (cont'd)

11. List all foreign entities that the taxpayer controlled or had a beneficial interest in at any time after 12/31/2001. Include the name of
the entity, type of entity, the foreign country where it is located, and the relationship to the taxpayer.
Name

Type of Entity

Country

Relationship to Taxpayer

12. Identify the source of funds or assets kept in the foreign accounts or held by the foreign entities described above (e.g, savings,
domestic business entities such as corporations or partnerships, domestic trusts, foreign business, gifts, inheritance). Include the
name of the source, the address, the relationship to the taxpayer and, for domestic entities, the EIN.
Name of Source

EIN

Address

Section III

Relationship to Taxpayer

Penalties

I/We believe that I/we qualify for the 10% penalty under Section 4 of Rev. Proc. 2008-68
because I/we meet all of the requirements of paragraph 3 of that section.

Yes

No

Under penalties of perjury, I/we declare that I/we have examined these statements, and to the best of
my/our knowledge and belief, they are true, correct, and complete.

Taxpayer
Attestation

Signature of Taxpayer

Date

Signature of Taxpayer

Date

Instructions
Send your completed Form 13982-A via e-mail to
[email protected] or by regular mail to:

If you are under examination (or in Appeals) please send a
copy of this Election to the IRS examiner (or IRS Appeals
Officer).

Internal Revenue Service
Attn: Rev. Proc. 2008-XX
P.O. Box 21229
Philadelphia, PA 19114

For additional information, please refer to the IRS website
at www.irs.gov. A link to Rev. Proc. 2008-xx will be
displayed on the main page.

Privacy Act Statement
The Privacy Act of 1974 says that when we ask you for information, we must first tell you our legal right to ask for the information, why we are asking for it, and how it will be
used. We must also tell you what could happen if you do not provide it and whether or not you must respond under the law.
This notice applies to tax returns and any papers filed with them. It also applies to any questions we need to ask you so we can complete, correct, or process your return;
figure your tax; and collect tax, interest, or penalties.
Our legal right to ask for information is found in Internal Revenue Code sections 6001, 6011, and 6012(a) and their regulations. They say that you must file a return or
statement with us for any tax you are liable for. Your response is mandatory under these sections.
Code section 6109 and its regulations say that you must show your social security number, employer identification number or individual taxpayer identification number on
what you file. Section 6109 also requires return preparers to provide their identifying numbers on the return. You must also fill in all parts of the tax form that apply to you. This
is so we know who you are and can process your return and papers.
We ask for tax return information to carry out the U.S. tax laws. We need it to figure and collect the right amount of tax. We may give the information to the Department of
Justice and to other federal agencies, as provided by law. We may also give it to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out
their tax laws. And we may give it to certain foreign governments under tax treaties they have with the United States. We may also disclose this information to federal and
state agencies to enforce federal non-tax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If you do not file a return, do not give us
the information we ask for, or provide fraudulent information, the law says that we may have to charge you penalties and, in certain cases, subject you to criminal prosecution.
We may also have to disallow the exemptions, exclusions, credits, deductions, or adjustments shown on your tax return. This could make your tax higher or delay any refund.
Interest may also be charged.

Catalog Number 52524P

www.irs.gov

Form 13982-A (Rev. 11-2008)