Form 8966 - Fatca Report - 2014
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28966
FATCA Report
OMB No. 1545-2246
Form
2014
Department of the Treasury
Information about Form 8966 and its separate instructions is at
▶
Internal Revenue Service
Check if report is being corrected, amended, or voided
Corrected report
Amended report
Voided report
Part I
Identification of Filer
1
Name of Filer
2
Number, street, and room or suite no. (if P.O. box, see instructions)
3c Country (including postal code)
3a City or town
3b
State/Province/Region
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)
8b State/Province/Region
8c Country (including postal code)
8a City or town
9 GIIN
10 TIN
.
.
.
Part II
Account Holder or Payee Information
1 Name of Account Holder or Payee
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3b State/Province/Region
3c Country (including postal code)
3a City or town
4 TIN
5 If account holder or payee is an entity, check applicable box to specify the entity's 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
Direct Reporting NFFE
Part III
Identifying Information of U.S. Owners that are specified U.S. Persons
1 Name of Owner
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3b State/Province/Region
3c Country (including postal code)
3a City or town
4 TIN of Owner
Part IV
Financial Information
1 Account Number
2 Currency Code
3 Account Balance
4a Interest
4c Gross proceeds/Redemptions
4b Dividends
4d Other
8966
For Paperwork Reduction Act Notice, see separate instructions.
Form
(2014)
Cat. No. 55748F
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