Form 8966 FATCA Report

Caution: DRAFT—NOT FOR FILING
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Form

8966

FATCA Report

Department of the Treasury
Internal Revenue Service

▶ Information

OMB No. XXXX-XXXX

about Form 8966 and its separate instructions is at www.irs.gov/form8966.

2014

Check if report is being corrected
Corrected report

Part I

DRAFT AS OF
August 13, 2013
DO NOT FILE
Identification of Filer

1

Name of Filer (Reporting FI, PFFI, Sponsoring Entity, or Other Withholding Agent)

2

Number, street, and room or suite no. (if P.O. box, see instructions)

3a City or town

3b

3c Country (including postal code)

State/Province/Region

4 Global Intermediary Identification Number (GIIN)

5 TIN

6 Name of Sponsored FFI or other Intermediary, if applicable

7 Number, street, and room or suite no. (if P.O. box, see instructions)

8b State/Province/Region

8a City or town
9 GIIN

10 TIN

-

Part II

8c Country (including postal code)

-

-

Account Holder or Recipient Information

1 Name of Account Holder or Recipient
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town

3b State/Province/Region

3c Country (including postal code)

4 TIN

5 If account holder or recipient is an entity, check applicable box to specify the entity's type:
Owner-Documented FI with specified U.S. owner(s)

Passive Non-Financial Entity with substantial U.S. owner(s)

Non-Participating FI

Specified U.S. Person

Part III

Identifying Information of U.S. Owners that are specified U.S. Persons

1 Name of Owner
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town

3b State/Province/Region

3c Country (including postal code)

4 TIN of Owner

Part IV

Financial Information

1 Account Number

2 Currency Code

3 Account Balance
4a Interest

4c Gross proceeds/Redemptions

4b Dividends

4d Other

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 55748F

Form

8966

(2014)

Page 2

Form 8966 (2014)

Part V

Pooled Reporting Type

1 Check applicable Pooled Reporting Type (check only one):
Recalcitrant account holders with U.S. Indicia

Recalcitrant account holders without U.S. Indicia

Dormant Accounts

Non-participating foreign financial institutions

Recalcitrant account holders that are U.S. persons

Recalcitrant account holders that are passive NFFEs

DRAFT AS OF
August 13, 2013
DO NOT FILE

2 Number of Accounts

3 Aggregate payment amount

4 Aggregate account balance

5 Currency Code

Form

8966

(2014)