Form 8957 - Foreign Account Tax Compliance Act (Fatca) Registration Page 4
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4Form 8957 (Rev. 10-2015)
4
Page
Part 2
Expanded Affiliated Group (continued)
13a
Is the Financial Institution the Common Parent Entity of the Expanded Affiliated Group?
Yes (If “Yes,” go to line 14)
No (If “No,” complete line 13b)
b
Enter the Legal Name of the Expanded Affiliated Group’s Common Parent Entity. Also enter the FATCA ID (if known).
Legal Name of the Common Parent Entity
▶
FATCA ID
▶
Part 3
Renewal of Agreement for QIs, WPs, or WTs
14
Has QI/WP/WT's legal name changed since the effective date of its most recent QI/WP/WT agreement?
Yes. Provide new legal business name
Provide reason for name change
Merger
Liquidation
Re-branding (name change only)
No
15
Responsible Party
Legal Name of Responsible Party
Last (Family)
First (Given)
Middle
Business Title
Business Telephone Number
Business Fax Number
Business Email Address of Responsible Party
Is the responsible party the same person listed as the RO for the Financial Institution?
Yes
No
16
Identify any private arrangement intermediary (PAI) contracts that are effective:
Legal Name of PAI
Country/Jurisdiction
Address Line 1
Address Line 2
City
State/Province/Region
ZIP/ Postal Code
Use additional sheets to add more PAIs.
Email Address of PAI
Part 4
SIGNATURE
By checking this box, I,
, certify that, to the best of my knowledge, the information submitted above is accurate and
complete and I am authorized to agree that the Financial Institution (including its branches, if any) will comply with its FATCA obligations in
accordance with the terms and conditions reflected in regulations, intergovernmental agreements, and other administrative guidance to the
extent applicable to the Financial Institution based on its status in each jurisdiction in which it operates.
I declare that I have examined this form including any accompanying statements, and to the best of my knowledge and belief, it is true, correct, and
complete.
Sign
Here
Date
Signature
8957
Form
(Rev. 10-2015)
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