Form 8957 - Foreign Account Tax Compliance Act (Fatca) Registration Page 2
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Form 8957 (Rev. 6-2017)
Page
6
Indicate whether the Financial Institution has in effect a withholding agreement with the IRS to be treated as one of the following:
a
Qualified Intermediary (QI)
Provide QI EIN:
-
Does the Financial Institution intend to maintain its status as a QI?
Yes
No
b
Withholding Foreign Partnership (WP)
Provide WP EIN:
-
Does the Financial Institution intend to maintain its status as a WP?
Yes
No
c
Withholding Foreign Trust (WT)
Provide WT EIN:
-
Does the Financial Institution intend to maintain its status as a WT?
Yes
No
d
Not applicable
7
Does the Financial Institution maintain a branch in a jurisdiction outside of its country/jurisdiction of tax residence?
Yes (If “Yes,” complete lines 8 and 9)
No (If “No,” go to line 10)
8
Is the Financial Institution a tax resident of the United States or does it maintain a branch in the United States (other than the U.S.
territories)?
Yes
Provide the U.S. EIN of the U.S. Financial Institution or U.S. branch:
-
No
9
List each jurisdiction (other than the United States) in which the Financial Institution maintains a branch. Also please list branches
maintained in any of the U.S. territories. If none, leave blank and go to line 10.
(Use additional sheets to add branches.)
10
FATCA Responsible Officer (RO) for the Financial Institution
Business Title of RO
Legal Name
Last (Family)
First (Given)
Middle
City
Country/Jurisdiction
Business Address Line 1
State/Province/Region
Business Address Line 2
ZIP/Postal Code
Business Telephone Number
Business Fax Number
Business Email Address of RO
8957
Form
(Rev. 6-2017)
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