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Form 8938 (2016)
Page
(Continuation Statement)
Name(s) shown on returnTIN
Part V
Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions)
1
Type of account
DepositCustodial
2 Account number or other designation
3Check all that applya
Account opened during tax yearbAccount closed during tax year
c
Account jointly owned with spouse
d
No tax item reported in Part III with respect to this asset
4Maximum value of account during tax year ..................... $
5Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? ..
YesNo
6If you answered “Yes” to line 5, complete all that apply.
(a) Foreign currency in which
account is maintained
(b) Foreign currency exchange rate used to
convert to U.S. dollars
(c) Source of exchange rate used if not from U.S.
Treasury Department's Bureau of the Fiscal Service
7 a
Name of financial institution in which account is maintainedb GIIN (Optional)
...
8
Mailing address of financial institution in which account is maintained. Number, street, and room or suite no.
9
City or town, state or province, and country (including postal code)
Part VIDetailed Information for Each “Other Foreign Asset” Included in the Part II Summary (see instructions)
1
Description of asset
2 Identifying number or other designation
3Complete all that apply. See instructions for reporting of multiple acquisition or disposition dates.
a
Date asset acquired during tax year, if applicable ..................
b
Date asset disposed of during tax year, if applicable .................
c
Check if asset jointly owned with spousedCheck if no tax item reported in Part III with respect to this asset
4Maximum value of asset during tax year (check box that applies)
a
$0 - $50,000b$50,001 - $100,000c$100,001 - $150,000d$150,001 - $200,000
e
If more than $200,000, list value ........................$
5Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? ...
YesNo
6If you answered “Yes” to line 5, complete all that apply.
(a) Foreign currency in which asset
is denominated
(b) Foreign currency exchange rate used to
convert to U.S. dollars
(c) Source of exchange rate used if not from U.S.
Treasury Department's Bureau of the Fiscal Service
7
If asset reported on line 1 is stock of a foreign entity or an interest in a foreign entity, enter the following information for the asset.
a
Name of foreign entityb GIIN (Optional)
...
cType of foreign entity(1)
Partnership(2)Corporation(3)
Trust(4)Estate
dMailing address of foreign entity. Number, street, and room or suite no.
e
City or town, state or province, and country (including postal code)
8
If asset reported on line 1 is not stock of a foreign entity or an interest in a foreign entity, enter the following information for the
asset.
a
Name of issuer or counterparty
Check if information is for
IssuerCounterparty
bType of issuer or counterparty
(1)Individual(2)Partnership(3)Corporation(4)Trust(5)Estate
cCheck if issuer or counterparty is a
U.S. personForeign person
dMailing address of issuer or counterparty. Number, street, and room or suite no.
eCity or town, state or province, and country (including postal code)
Form 8938 (2016)