Version A, Cycle 13
Form 8957 (7-2013)
3
Page
11b
This question 11b must be completed by the Financial Institution's RO. Upon entering the POC information below, checking the box
that follows, and submitting this registration form, the RO is providing the IRS with written authorization to release FATCA information
to the POC. This authorization specifically includes authorization for the POC to complete this Form 8957: FATCA Registration, to take
other FATCA-related actions, and to obtain access to the Financial Institution's tax information.
Legal Name of POC
Last (Family)
First (Given)
Middle
Business Title
City
Country
Business address Line 1
Business address Line 2
State/Province/Region
ZIP/Postal Code
Business telephone number
Business fax number
Business email address of RO
Five POCs are allowed per Financial Institution. Use additional sheets to add POCs.
Internal Use Only
By checking this box,
I,
, as RO for the Financial Institution, provide the authorization described above to the
identified POCs listed in this question 11b. Once this authorization is granted, it is effective until revoked by either the Financial
Institution or the POC.
Part 2
DRAFT AS OF
Expanded Affiliated Group
Lead financial institutions must read the instructions before filling out Part 2.
12
Provide the following for each Financial Institution member of the Expanded Affiliated Group
April 23, 2013
Legal name of member Financial Institution
Country of residence for tax purposes
Member type *
* Enter one of the following:
Participating Financial Institution not covered by an IGA; or a Reporting Financial Institution under a Model 2 IGA
Deemed-Compliant Financial institution (including a Reporting Financial institution under a Model 1 IGA)
Limited Financial Institution
Part 3
Renewal of Agreement for QIs, WPs, or WTs
13
Has QI/WP/WT's legal name changed since the effective date of its most recent QI/WP/WT agreement?
Yes. Provide new legal business name
Provide reason for name change
Merger
Liquidation
Re-branding (name change only)
No
8957
Form
(7-2013)