Form 3520-A - Annual Information Return Of Foreign Trust With A U.s. Owner - 2015 Page 3

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3
Form 3520-A (2015)
Page
2015 Foreign Grantor Trust Owner Statement (see instructions)
Important: Trustee must prepare a separate statement for each U.S. owner and include a copy of each statement with Form 3520-A. Trustee is also
required to send to each U.S. owner a copy of the owner’s statement. U.S. owner must attach a copy of its statement to Form 3520.
1a
Name of foreign trust
b(1)
Employer identification number
c
b(2)
Reference ID number (see instructions)
Number, street, and room or suite no. (if a P.O. box, see instructions)
d
City or town
e State or province
f ZIP or foreign postal code
g
Country
2
Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust information?
Yes
No
If “Yes,” complete lines 3a through 3g.
3a
b
Name of U.S. agent
Identification number
c
Number, street, and room or suite no. (if a P.O. box, see instructions)
d
City or town
e State or province
f ZIP or postal code
g
Country
4a
Name of trustee
b
Identification number (if any)
c
Number, street, and room or suite no. (if a P.O. box, see instructions)
d
e State or province
f ZIP or postal code
g
City or town
Country
5
The tax year of the owner of the foreign trust to which this statement relates
6a
Name of U.S. owner
b
Identification number
c
Number, street, and room or suite no. (if a P.O. box, see instructions)
d
City or town
e State or province
f ZIP or postal code
g
Country
h
Service Center where U.S. owner files its income tax returns
Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion
7
of the foreign trust) is treated for U.S. tax principles as owned by the U.S. person.
8
If the trust did not appoint a U.S. agent, list the trust documents attached to Form 3520-A (see instructions).
$
9
Gross value of the portion of the trust treated as owned by the U.S. owner .
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2015 Statement of Foreign Trust Income Attributable to U.S. Owner (see instructions)
Report each item on the proper form or schedule of your tax return.
1a
Taxable interest .
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b
Tax-exempt interest
2a
Total ordinary dividends .
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b
Qualified dividends
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Gross rents and royalties
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Income from partnerships and fiduciaries .
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Capital gains (losses)
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Ordinary gains (losses) .
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Other income (attach statement)
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Interest expense .
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9a
Foreign taxes (attach statement)
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b
State and local taxes
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10
Amortization and depreciation (depletion)
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Trustee and advisor fees.
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12
Charitable contributions .
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Other expenses (attach statement) .
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Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge and
belief, it is true, correct, and complete.
Trustee Signature
Title
Date
3520-A
Form
(2015)

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