8966
FATCA Report
OMB No. 1545-2246
Form
2017
Department of the Treasury
Go to for instructions and the latest information.
▶
Internal Revenue Service
Check if report is being corrected, amended, voided, or there are no accounts to report:
Corrected report
Amended report
Voided report
Check if no accounts to report (see instructions)
Part I
Identification of Filer
1b Enter the filer category (see instructions)
1a Name of filer
▶
2
Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town
3b
State, province, or region
3c Country, including postal code
4 Global intermediary identification number (GIIN)
5 TIN
.
.
.
6 Name of sponsored entity or intermediary, if applicable
7 Number, street, and room or suite no. (if P.O. box, see instructions)
8a City or town
8b State, province, or region
8c Country, including postal code
9 GIIN
10 TIN
.
.
.
Part II
Account Holder or Payee Information
1b Indicate whether account holder or payee is an individual or entity
1a Name of account holder or payee
Individual
Entity
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town
3b State, province, or region
3c Country, including postal code
4 TIN
5 If account holder or payee is an entity, check applicable box to specify the entity type:
Owner-Documented FFI with specified U.S. Owner(s)
Passive NFFE with substantial U.S. Owner(s)
Non-Participating FFI
Specified U.S. Person
Part III
Owner Information (File a separate report for each U.S. Owner that is a specified U.S. Person.)
1 Name of owner
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town
3b State, province, or region
3c Country, including postal code
4 TIN of owner
Part IV
Financial Information
1 Account number
2 Currency code (see instructions)
3a Account balance
3b Check if account closed during the year (see instructions)
4a Interest
4c Gross proceeds/Redemptions
4b Dividends
4d Other
8966
For Paperwork Reduction Act Notice, see separate instructions.
Form
(2017)
Cat. No. 55748F