Fatca Form - U.s. Person Status Form printable pdf download

FATCA FORM

U.S. PERSON STATUS FORM

DETERMINING YOUR STATUS AS A U.S. PERSON OR NON-U.S. PERSON

Question 1

Are you or were you ever a U.S. citizen? (Including dual nationality)

Yes 

No 

Question 2

Were you born in the United States or a U.S. territory?

Yes 

No 

(U.S. territories: American Samoa, Federated States of Micronesia,

Guam, Midway Islands, Northern Mariana Islands, Puerto Rico,

Republic of Palau, U.S. Virgin Islands)

Question 3

Are you or were you ever a lawful permanent resident of the U.S. (i.e., a green

card holder)?

Yes 

No 

If you answered yes to any of the questions above, but are no longer a U.S. citizen or lawful permanent resident,

please provide us with: (i) an explanation regarding your renunciation of U.S. citizenship or the reason you did not

obtain U.S. citizenship at birth; (ii) a copy of your Non-U.S. Passport; (iii) a valid and completed Form W-8BEN

(Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals); (iv) a

copy of your (A) Certificate of Loss of Nationality of the United States (if formerly a citizen), or (B) Form I-407

(Abandonment of Lawful Permanent Residence Status) which was filed with a U.S. Embassy (if formerly a lawful

permanent resident); and (v) complete a Non U.S. Person Declaration.

If you answered “yes” to any of the questions above and you are a U.S. citizen or lawful permanent resident, please

provide a valid and completed Form W-9, Request for Taxpayer Identification Number and Certification.

In order to determine if you are a resident alien of the United States, please answer the following questions:

Question 4

Do you have a temporary or permanent place of residence in the United States?

Yes 

No 

If you answered yes to Question 4 and you are not a US Person, please complete Non US Person Letter of

Explanation of US Address.

Question 5

Have you been issued a U.S. visa which has not yet expired?

Yes 

No 

If so, please list the type of visa, the date of issuance and the date of expiration:

Type of visa: _______________________

Date of issuance: ____________________

Date of expiration ___________________

Also, please provide us with a copy of the visa for the Bank’s records.

Question 6

During calendar years 2011, 2012 and/or 2013, did you spend any time within the United States? If

so, please provide the number of days of presence for each year below, and calculate the number of

Fatca Form - U.s. Person Status Form

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