Form 8938 - Statement Of Specified Foreign Financial Assets
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38938
Statement of Specified Foreign Financial Assets
OMB No. 1545-2195
2015
Form
Information about Form 8938 and its separate instructions is at
▶
Attach to your tax return.
▶
Department of the Treasury
Attachment
For calendar year 20
or tax year beginning
, 20
and ending
, 20
Internal Revenue Service
Sequence No. 175
If you have attached continuation statements, check here
Number of continuation statements
Name(s) shown on return
TIN
Part I
Foreign Deposit and Custodial Accounts Summary
Number of Deposit Accounts (reported on Form 8938) .
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Maximum Value of All Deposit Accounts
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Number of Custodial Accounts (reported on Form 8938)
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Maximum Value of All Custodial Accounts .
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5
Were any foreign deposit or custodial accounts closed during the tax year? .
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Yes
No
Part II
Other Foreign Assets Summary
Number of Foreign Assets (reported on Form 8938) .
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Maximum Value of All Assets
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$
3
Were any foreign assets acquired or sold during the tax year?
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Yes
No
Part III
Summary of Tax Items Attributable to Specified Foreign Financial Assets (see instructions)
(c) Amount reported on
Where reported
form or schedule
(a) Asset Category
(b) Tax item
(d) Form and line
(e) Schedule and line
1 Foreign Deposit and
1a Interest
$
Custodial Accounts
1b Dividends
$
1c Royalties
$
1d Other income
$
1e Gains (losses)
$
1f Deductions
$
1g Credits
$
2 Other Foreign Assets
2a Interest
$
2b Dividends
$
2c Royalties
$
2d Other income
$
2e Gains (losses)
$
2f Deductions
$
2g Credits
$
Part IV
Excepted Specified Foreign Financial Assets (see instructions)
If you reported specified foreign financial assets on one or more of the following forms, enter the number of such forms filed. You do
not need to include these assets on Form 8938 for the tax year.
1. Number of Forms 3520
2. Number of Forms 3520-A
3. Number of Forms 5471
4. Number of Forms 8621
5. Number of Forms 8865
Part V
Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions)
If you have more than one account to report, attach a continuation statement for each additional account (see instructions).
Type of account
Deposit
Custodial
2 Account number or other designation
1
3
a
b
Check all that apply
Account opened during tax year
Account closed during tax year
c
Account jointly owned with spouse
d
No tax item reported in Part III with respect to this asset
4
Maximum value of account during tax year .
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$
5
Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? .
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Yes
No
6
If you answered “Yes” to line 5, complete all that apply.
(a) Foreign currency in which
(b) Foreign currency exchange rate used to
(c) Source of exchange rate used if not from U.S.
account is maintained
convert to U.S. dollars
Treasury Department's Bureau of the Fiscal Service
8938
For Paperwork Reduction Act Notice, see the separate instructions.
Form
(2015)
Cat. No. 37753A
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