Form 8957 Form 8957 Foreign Account Tax Compliance Act (FATCA) Registration

Version A, Cycle 5

Form

8957

(Rev. October 2015)
Department of the Treasury
Internal Revenue Service

Foreign Account Tax Compliance Act (FATCA) Registration
▶

OMB No. 1545-2246

Information about Form 8957 and its separate instructions is at www.irs.gov/form8957.

• All applicants must complete Part 1.
• This form will not be processed if it is not signed.
• DO NOT fill out this form if you have begun registering at http://www.irs.gov/fatca.
• The IRS strongly recommends that applicants register by accessing the online version of this form at http://www.irs.gov/fatca. The
use of this paper form will take longer for the IRS to process and if any information is missing or incomplete the delay in
registration may be significant.
• This form should be mailed to:
FATCA, Stop 6099 AUSC
3651 South IH 35
Austin, Texas 78741

Part 1
1

Financial Institution Registration

Select Financial Institution Type (check only one)
Single (not a member of an Expanded Affiliated Group)
Lead of an Expanded Affiliated Group
Member (not Lead) of an Expanded Affiliated Group. If a Member, you must provide the FATCA ID issued for such Member and provided
by your Lead:
Sponsoring Entity

2

3a
b
4

INTERNAL USE ONLY
DRAFT AS OF
June 26, 2015
Legal Name of the Financial Institution

What is the Financial Institution's country/jurisdiction of residence for tax purposes?
What is the Financial Institution's country/jurisdiction tax ID?

Select the Financial Institution's FATCA classification in its country/jurisdiction of tax residence (check only one)
Participating Financial Institution not covered by an IGA; or a Reporting Financial Institution under a Model 2 IGA
Registered Deemed-Compliant Financial Institution (including a Reporting Financial Institution under a Model 1 IGA)
Limited Financial Institution
None of the above

5

Mailing Address of Financial Institution
Country/Jurisdiction
Address Line 1
Address Line 2
City

For Paperwork Reduction Act Notice, see separate instructions.

State/Province/Region

ZIP/Postal Code
Cat. No. 37778V

Form

8957 (Rev. 10-2015)

Version A, Cycle 5
Form 8957 (Rev. 10-2015)

6
a

Page

2

Indicate whether the Financial Institution has in effect a withholding agreement with the IRS to be treated as one of the following:
Qualified Intermediary (QI)
Provide QI EIN:
Does the Financial Institution intend to maintain its status as a QI?
Yes
No

b

Withholding Foreign Partnership (WP)
Provide WP EIN:
Does the Financial Institution intend to maintain its status as a WP?
Yes
No

c

Withholding Foreign Trust (WT)
Provide WT EIN:
Does the Financial Institution intend to maintain its status as a WT?
Yes
No

d
7

Not applicable

INTERNAL USE ONLY
DRAFT AS OF
June 26, 2015
Does the Financial Institution maintain a branch in a jurisdiction outside of its country/jurisdiction of tax residence?
Yes (If “Yes,” complete lines 8, 9a, 9b, and 9c)
No (If “No,” go to line 10)

Is the Financial Institution a tax resident of the United States or does it maintain a branch in the United States (other than the U.S. territories)?
Yes Provide the U.S. EIN of the U.S. Financial Institution or U.S. branch:

8

-

No

9a

b

List each jurisdiction (other than the United States) in which the Financial Institution maintains a branch. Also please list branches
maintained in any of the U.S. territories. If none, leave blank and go to line 10.

Is the branch a Limited Branch?
Yes
No

c

If the branch is currently covered by a QI agreement, does the Financial Institution intend to maintain QI status for that branch?
Yes
No
Not applicable
(Use additional sheets to add branches.)

10

FATCA Responsible Officer (RO) for the Financial Institution
Business Title of RO
Legal Name
Last (Family)

First (Given)

Middle

Country/Jurisdiction

City
Business Address Line 1
Business Address Line 2
Business Telephone Number

State/Province/Region
Business Fax Number

ZIP/Postal Code
Business Email Address of RO
Form

8957

(Rev. 10-2015)

Version A, Cycle 5
Page 3

Form 8957 (Rev. 10-2015)

11a

b

The Financial Institution's RO will be a point of contact (POC) for the Financial Institution. In addition, the RO of a Financial Institution
registering as a Lead of all or part of an Expanded Affiliated Group will be a POC for each Member of that group.
Does the RO or an Authorizing Individual wish to designate one or more additional POCs for the Financial Institution?
Yes (If “Yes,” complete line 11b)
No (If “No,” go to line 12)
This line 11b must be completed by the Financial Institution's RO or an Authorizing Individual. Upon entering the POC information
below, checking the box that follows, and submitting this registration form, the RO or Authorizing Individual is providing the IRS with
written authorization to release FATCA information to the POC. This authorization specifically includes authorization for the POC to
complete this Form 8957: FATCA Registration, to take other FATCA-related actions, and to obtain access to the Financial Institution's
tax information.
Business Title of POC

Legal Name of POC
Last (Family)

First (Given)

Middle

Country/Jurisdiction

City
Business Address Line 1

INTERNAL USE ONLY
DRAFT AS OF
June 26, 2015
Business Address Line 2

Business Telephone Number

State/Province/Region

Business Fax Number

ZIP/Postal Code

Business Email Address of POC

Five POCs are allowed per Financial Institution. Use additional sheets to add POCs.

By checking this box, I,
, as RO or Authorizing Individual for the Financial Institution, provide the authorization
described above to the identified POCs listed in this line 11b. Once this authorization is granted, it is effective until revoked by either
the Financial Institution or the POC.

Part 2

12

Expanded Affiliated Group

Lead Financial Institutions must read the instructions before completing Part 2.
Provide the following for each Financial Institution member of the Expanded Affiliated Group
Legal name of Member Financial Institution

Country/Jurisdiction of residence for tax

purposes

Member type *

* Enter one of the following:
Participating Financial Institution not covered by an IGA; or a Reporting Financial Institution under a Model 2 IGA
Registered Deemed-Compliant Financial institution (including a Reporting Financial Institution under a Model 1 IGA)
Limited Financial Institution
Form

8957

(Rev. 10-2015)

Version A, Cycle 5
Page 4

Form 8957 (Rev. 10-2015)

Part 2
13a

Expanded Affiliated Group (continued)

Is the Financial Institution the Common Parent Entity of the Expanded Affiliated Group?
Yes (If “Yes,” go to line 14)
No (If “No,” complete line 13b)

b

Enter the Legal Name of the Expanded Affiliated Group’s Common Parent Entity. Also enter the FATCA ID (if known).
Legal Name of the Common Parent Entity ▶
FATCA ID ▶

Part 3
14

Renewal of Agreement for QIs, WPs, or WTs

Has QI/WP/WT's legal name changed since the effective date of its most recent QI/WP/WT agreement?
Yes. Provide new legal business name
Provide reason for name change
Merger
Liquidation
Re-branding (name change only)
No

15

INTERNAL USE ONLY
DRAFT AS OF
June 26, 2015
Responsible Party
Legal Name of Responsible Party

Last (Family)

First (Given)

Middle

Business Title

Business Telephone Number

Business Fax Number

Business Email Address of Responsible Party

Is the responsible party the same person listed as the RO for the Financial Institution?
Yes
No

16

Identify any private arrangement intermediary (PAI) contracts that are effective:
Legal Name of PAI

Country/Jurisdiction
Address Line 1
Address Line 2
City

State/Province/Region

Email Address of PAI

Part 4

ZIP/ Postal Code

Use additional sheets to add more PAIs.

SIGNATURE

By checking this box, I,
, certify that, to the best of my knowledge, the information submitted above is accurate and
complete and I am authorized to agree that the Financial Institution (including its branches, if any) will comply with its FATCA obligations in
accordance with the terms and conditions reflected in regulations, intergovernmental agreements, and other administrative guidance to the
extent applicable to the Financial Institution based on its status in each jurisdiction in which it operates.

Signature

▲

▲

Sign
Here

I declare that I have examined this form including any accompanying statements, and to the best of my knowledge and belief, it is true, correct, and
complete.

Date
Form

8957

(Rev. 10-2015)