Form 8957 - Foreign Account Tax Compliance Act (Fatca) Registration Page 2
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Form 8957 (8-2013)
Page
7
Does the Financial Institution maintain a branch in a jurisdiction outside of its country of tax residence?
Yes (If “Yes,” complete lines 8, 9a, 9b, and 9c)
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:
-
eg: 00-0000000
No
9a
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.
b
Is the branch a Limited Branch?
Yes
No
c
If the branch is currently covered by a QI agreement, does the Financial Institution intend to maintain QI status for that branch?
Yes
No
Not applicable
(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
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
11a
The Financial Institution's RO will be a point of contact (POC) for the Financial Institution. In addition, the RO of a Financial Institution
registering as a Lead of all or part of an Expanded Affiliated Group will be a POC for each Member of that group.
Does the RO wish to designate one or more additional POCs for the Financial Institution?
Yes (If “Yes,” complete line 11b)
No (If “No,” go to line 12)
8957
Form
(8-2013)
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