Form 8938 - Statement Of Specified Foreign Financial Assets Page 3
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Form 8938 (2015)
(Continuation Statement)
Name(s) shown on return
TIN
Part V
Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions)
2 Account number or other designation
Type of account
Deposit
Custodial
1
3
Check all that apply
a
Account opened during tax year
b
Account closed during tax year
c
d
Account jointly owned with spouse
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
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)
2 Identifying number or other designation
Description of asset
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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
Check if asset jointly owned with spouse
d
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? .
.
.
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)
(2)
(3)
(4)
Partnership
Corporation
Trust
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.
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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