Form 8966 FATCA Report

Form

8966

FATCA Report

Department of the Treasury
Internal Revenue Service

a Information

OMB No. 1545-2246

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

2014

Check if report is being corrected, amended, or voided
Corrected report

Part I

Amended report

Voided report

Identification of Filer

1

Name of Filer

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 Entity or 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 Payee Information

1 Name of Account Holder or Payee

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 payee is an entity, check applicable box to specify the entity's type:
Owner-Documented FFI with specified U.S. owner(s)

Passive NFFE with substantial U.S. owner(s)

Non-Participating FFI

Specified U.S. Person

Direct Reporting NFFE

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 FFI

Recalcitrant account holders that are U.S. persons

Recalcitrant account holders that are passive NFFEs

2 Number of Accounts

3 Aggregate payment amount

4 Aggregate account balance

5 Currency Code

Form

8966

(2014)