Fatca Form - U.s. Person Status Form (Page 2 of 3) in pdf

Fatca Form - U.s. Person Status Form Page 2

FATCA FORM

U.S. PERSON STATUS FORM

days of presence under the so-called “Substantial Presence Test” (do not round fractions to the

nearest whole number.)

2013:

_______________________

Multiplied by 1 = __________________ = (A)

Number of Days in the U.S.

2012:

_______________________

Multiplied by 1/3 = __________________ = (B)

Number of Days in the U.S.

2011:

_______________________

Multiplied by 1/6 = __________________ = (C)

Number of Days in the U.S.

Total Number of Days Under the Substantial Presence Test

(A) + (B) +

(C)

Total Number of Days Under the Substantial Presence Test

______ + _____ + _____

Total Number of Days Under the Substantial Presence Test

____________________

Question 7

Under the Substantial Presence Test calculation (above), were you present in the United States for at

least 183 days?

Yes 

No 

Question 8

If you answered yes to Question 7, then please indicate whether you ever filed IRS Form 8840

(Closer Connection Statement) or IRS Form 8833 (Treaty-Based Return Position Disclosure)?

Yes 

No 

Form 8840

Yes 

No 

Form 8833

If you ever filed Form 8840 or Form 8833, please provide us with a copy of the applicable Form as filed with the IRS

for our records.

Question 9

Are you tax resident in the United States for any other reason?

Yes 

No 

(e.g. joint tax declaration as a married couple) If yes, please provide another explanation of your status as a tax

resident in the United States:

______________________________________________________________________________________________

IFY OU HAVE ANSWERED “NO” TO QUESTIONS 1 THROUGH 7 AND “NO” TO QUESTION 9 AND YOU ARE NOT A U.S.

PERSON, THEN PLEASE COMPLETE A NON U.S. PERSON DECLARATION AND PROVIDE A VALID AND COMPLETED

FORM W-8BEN.

Fatca Form - U.s. Person Status Form Page 2

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