Form 8938 Statement of Foreign Financial Assets

DRAFT FORM xxxxx -STATEMENT OF FOREIGN FINANCIAL ASSETS
Form

8938

(Rev. July 2010) Dept.of
the Treasury Internal
Revenue Service

Statement of Foreign Financial Assets >Attach OMB No. 1545-xxxx
to your tax return if you owned specified foreign financial assets having an
>See separate Attachment
aggregate value of more than $50,000.
Sequence No. XXX
instructions.

Name(s) shown on your income tax return

Identifying number

Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be
stated in U.S. dollars unless otherwise indicated.

Complete Part A if you held any interest in any financial account maintained by a foreign financial institution
during the taxable year (see instructions), and
Complete Part B if you held any interest in any stock or security issued by a person other than a United States
person (see instructions), and
Complete Part C if you held any interest in any financial instrument or contract held for investment that has an
issuer or counterparty which is other than a United States person (see instructions), and
Complete Part D if you held any interest in a foreign entity (see instructions).

Part A. Schedule of any financial asset maintained by a foreign financial institution (see
instructions).
Name of financial institution

Address of financial institution

Financial account
number

Maximum value of
account during
taxable year

Draft
Part B. Schedule of any stock or security issued by a person other than a U.S. person (see
instructions).
Name of issuer

Address of issuer

Description of stock Maximum value of
or security by class, stock or security
issue and type
during taxable year

Part C. Complete blocks (a) through (f) with schedule of any other instrument, contract or
interest (see instructions).
(b)

(c)

Name of issuer

Address of issuer

Description of other instrument, contract
or interest

(d)

(e)

(f)

Name of counterparty of
instrument, contract or interest

Address of counterparty

Maximum value of other instrument,
contract or interest during taxable year

(a)

Part D. Schedule of any interest in a foreign entity (see instructions).

Draft

Name of foreign entity

Address of foreign entity

Cat. No 37753A

Description of
interest held in
foreign entity

Maximum value of
interest in foreing
entity during taxable
year