Form 8938 - Statement Of Specified Foreign Financial Assets Page 2
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Form 8938 (2015)
Page
Part V
Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions) (continued)
7 a
Name of financial institution in which account is maintained
b Reserved
8
Mailing address of financial institution in which account is maintained. Number, street, and room or suite no.
9
City or town, state or province, and country (including postal code)
Part VI
Detailed Information for Each "Other Foreign Asset" Included in the Part II Summary (see instructions)
Note. If you reported specified foreign financial assets on Forms 3520, 3520-A, 5471, 8621, or 8865, you do not have to include the
assets on Form 8938. You must complete Part IV. See instructions.
If you have more than one asset to report, attach a continuation statement for each additional asset (see instructions).
2 Identifying number or other designation
Description of asset
1
3
Complete all that apply. See instructions for reporting of multiple acquisition or disposition dates.
a Date asset acquired during tax year, if applicable .
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b Date asset disposed of during tax year, if applicable .
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c
d
Check if asset jointly owned with spouse
Check if no tax item reported in Part III with respect to this asset
4
Maximum value of asset during tax year (check box that applies)
a
$0 - $50,000
b
$50,001 - $100,000
c
$100,001 - $150,000
d
$150,001 - $200,000
e If more than $200,000, list value
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$
5
Did you use a foreign currency exchange rate to convert the value of the asset 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 asset
(b) Foreign currency exchange rate used to
(c) Source of exchange rate used if not from U.S.
is denominated
convert to U.S. dollars
Treasury Department's Bureau of the Fiscal Service
7
If asset reported on line 1 is stock of a foreign entity or an interest in a foreign entity, enter the following information for the asset.
a Name of foreign entity
b Reserved
c Type of foreign entity
(1)
Partnership
(2)
Corporation
(3)
Trust
(4)
Estate
d Mailing address of foreign entity. Number, street, and room or suite no.
e City or town, state or province, and country (including postal code)
8
If asset reported on line 1 is not stock of a foreign entity or an interest in a foreign entity, enter the following information for the
asset.
Note. If this asset has more than one issuer or counterparty, attach a continuation statement with the same information for each
additional issuer or counterparty (see instructions).
a Name of issuer or counterparty
Check if information is for
Issuer
Counterparty
b Type of issuer or counterparty
(1)
Individual
(2)
Partnership
(3)
Corporation
(4)
Trust
(5)
Estate
c Check if issuer or counterparty is a
U.S. person
Foreign person
d Mailing address of issuer or counterparty. Number, street, and room or suite no.
e City or town, state or province, and country (including postal code)
8938
Form
(2015)
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