8966
FATCA Report
OMB No. 1545-2246
Form
2015
Department of the Treasury
Information about Form 8966 and its separate instructions is at
▶
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
1a Name of filer
1b Enter the filer category (see instructions)
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
(2015)
Cat. No. 55748F