8809-I Application for Extension of Time to File FATCA Form 896

Form

8809-I

Application for Extension of Time
to File FATCA Form 8966

(November 2015)
Department of the Treasury
Internal Revenue Service

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Information about Form 8809-I and its separate instructions is at www.irs.gov/form8809i.

1

Name of filer

2

Number, street, and room or suite no. If a P.O. box, see instructions.

3a City or town
4

OMB No. 1545-2246

3b State, province, or region
5

Filer global intermediary identification number (GIIN)
.

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6a Filer Point of Contact (POC) name

3c Country (including postal code)
Taxpayer identification number (TIN)

.

6b Filer POC email

7

Name of sponsored entity or intermediary, if applicable

8

Number, street, and room or suite no. If a P.O. box, see instructions.

9a City or town

6c Filer POC phone number

9b State, province, or region
11 TIN

10 GIIN of sponsored entity or intermediary
.

12 Check your method of filing Form 8966

9c Country (including postal code)

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.

.

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Electronic

Paper

13 Check this box only if you already requested the automatic extension and you now need an additional extension. See instructions

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14 If you checked the box on line 13, state in detail why you need an additional extension of time. You must provide sufficient cause as to why you
were not able to file by the date granted by the first extension request. If you need more space, attach additional sheets. Include the filer name,
TIN, and GIIN on each additional page.

Under penalties of perjury, 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.

Signature ▶

Title ▶
For Paperwork Reduction Act Notice, see separate instructions.

Date ▶
Cat. No. 67371G

Form 8809-I (11-2015)