Form 8966 FATCA Report

Form

8966

FATCA Report

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-2246

2017

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

Check if report is being corrected, amended, voided, or there are no accounts to report:
Corrected report

Part I

Amended report

Voided report

1b Enter the filer category (see instructions) ▶

1a Name of filer
2

Check if no accounts to report (see instructions)

Identification of Filer

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 (2017)

Page 2

Form 8966 (2017)

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 (2017)