Form 8957 - Foreign Account Tax Compliance Act (Fatca) Registration Page 3
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4Form 8957 (Rev. 10-2015)
3
Page
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 or an Authorizing Individual 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)
b
This line 11b must be completed by the Financial Institution's RO or an Authorizing Individual. Upon entering the POC information
below, checking the box that follows, and submitting this registration form, the RO or Authorizing Individual 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.
Business Title of POC
Legal Name of POC
Last (Family)
First (Given)
Middle
City
Country/Jurisdiction
Business Address Line 1
Business Address Line 2
State/Province/Region
ZIP/Postal Code
Business Telephone Number
Business Fax Number
Business Email Address of POC
Five POCs are allowed per Financial Institution. Use additional sheets to add POCs.
By checking this box, I,
, as RO or Authorizing Individual for the Financial Institution, provide the authorization
described above to the identified POCs listed in this line 11b. Once this authorization is granted, it is effective until revoked by either
the Financial Institution or the POC.
Part 2
Expanded Affiliated Group
Lead Financial Institutions must read the instructions before completing Part 2.
12
Provide the following for each Financial Institution member of the Expanded Affiliated Group
of residence for tax
Legal name of Member Financial Institution
Country/Jurisdiction
Member type *
purposes
* Enter one of the following:
Participating Financial Institution not covered by an IGA; or a Reporting Financial Institution under a Model 2 IGA
Registered Deemed-Compliant Financial institution (including a Reporting Financial Institution under a Model 1 IGA)
Limited Financial Institution
8957
Form
(Rev. 10-2015)
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