8966 FATCA Report

Caution: DRAFT—NOT FOR FILING
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Form

8966

FATCA Report

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-2246

2018

Go to www.irs.gov/Form8966 for instructions and the latest information.

If you are filing paper Forms 8966, enter the three-digit identifier number used to identify this Form 8966 filing
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶
Check if report is being corrected, amended, voided, or there are no accounts to report:
Corrected report
Amended report
Voided report
Check if no accounts to report (see instructions)

Part I

2

DRAFT AS OF
July 30, 2018
DO NOT FILE

Identification of Filer

1a Name of filer

1b Enter the filer category (see instructions) ▶

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, or 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)
8a City or town

8b State, province, or region

9 GIIN

Part II

8c Country, including postal code

10 TIN
.

.

.

Account Holder or Payee Information
1b Indicate whether account holder or payee is an individual or entity

1a Name of account holder or payee

Individual

Entity

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

3b State, province, or region

3c Country, including postal code

4 TIN

5 If account holder or payee is an entity, check applicable box to specify the entity 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

Part III

Owner Information (File a separate report for each U.S. Owner that is a specified U.S. Person.)

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, or region

3c Country, including postal code

4 TIN of owner

Part IV

Financial Information

1 Account number

2 Currency code (see instructions)

3a Account balance
3b Check if account closed during the year (see instructions)
4a Interest

4c Gross proceeds/Redemptions

4b Dividends

4d Other

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 55748F

Form 8966 (2018)

Page 2

Form 8966 (2018)

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

DRAFT AS OF
July 30, 2018
DO NOT FILE

2 Number of accounts

3 Aggregate payment amount

4 Aggregate account balance

5 Currency code

Form 8966 (2018)