Form 3520-A - Annual Information Return Of Foreign Trust With A U.s. Owner - 2015 Page 4

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Form 3520-A (2015)

Page

2015 Foreign Grantor Trust Beneficiary Statement

Important: Trustee must prepare a separate statement for each U.S. beneficiary that received a distribution from the trust during the tax year and

include a copy of each statement with Form 3520-A. Trustee is also required to send to each such beneficiary a copy of the beneficiary’s

statement. Each U.S. beneficiary must attach a copy of its statement to its Form 3520.

Name of foreign trust

b(1)

Employer identification number

Number, street, and room or suite no. (if a P.O. box, see instructions)

b(2)

Reference ID number (see instructions)

e State or province

f ZIP or foreign postal code

City or town

Country

Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust

Yes

information?

If “Yes,” complete lines 3a through 3g.

If “No,” do you agree that either the IRS or the U.S. beneficiary can inspect and copy the trust’s permanent books of

account, records, and such other documents that are necessary to establish that the trust should be treated for U.S.

Yes

tax purposes as owned by another person? .

Name of U.S. agent

Identification number

Number, street, and room or suite no. (if a P.O. box, see instructions)

City or town

e State or province

f ZIP or postal code

Country

Name of trustee

Identification number (if any)

Number, street, and room or suite no. (if a P.O. box, see instructions)

City or town

e State or province

f ZIP or postal code

Country

The first and last day of the tax year of the foreign trust to which Form 3520-A applies

▶

Name of U.S. beneficiary

Identification number

Number, street, and room or suite no. (if a P.O. box, see instructions)

City or town

e State or province

f ZIP or postal code

Country

Description of trust property (including cash) that was either (1) distributed, or treated as distributed, directly or indirectly to the U.S. person

who is a beneficiary of the trust or a U.S. person related to that U.S. person during the tax year or (2) used by the U.S. person who is a

beneficiary of the trust or a U.S. person related to that U.S. person without compensating the trust for the FMV of the use of the property within

a reasonable period of time. (See the instructions for Part III of Form 3520 for U.S. tax treatment of these amounts.)

(a) Description of property

(b) FMV

Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion

of the foreign trust) is treated for U.S. tax principles as owned by another person.

Owner of the foreign trust is (check one):

Individual

Partnership

Corporation

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)