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Form 3520-A (2015)
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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
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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
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Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion
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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).
$
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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
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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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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
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3520-A
Form
(2015)