Form 8966
Form
8966
Department of the Treasury
Internal Revenue Service
FATCA Report
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Information about Form 8966 and its separate instructions is at www.irs.gov/form8966.
OMB No. 1545-2246
2016
Check if report is being corrected, amended, voided, or there are no accounts to report
Corrected report Amended report Voided report Check if no accounts to report (see instructions)
Part I
Identification of Filer
1a Name of filer
1b Enter the filer category (see instructions)
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2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town 3b State, province, or region 3c Country, including postal code
4 Global intermediary identification number (GIIN)
. . .
5 TIN
6 Name of sponsored entity or intermediary, if applicable
7 Number, street, and room or suite no. (if P.O. box, see instructions)
8a City or town
8b State, province, or region 8c Country, including postal code
9 GIIN
. . .
10 TIN
Part II
Account Holder or Payee Information
1a Name of account holder or payee
1b Indicate whether account holder or payee is an individual or entity
Individual Entity
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town 3b State, province, or region 3c Country, including postal code
4 TIN
5 If account holder or payee is an entity, check applicable box to specify the entity type:
Owner-Documented FFI with specified U.S. owner(s) Passive NFFE with substantial U.S. owner(s)
Non-Participating FFI Specified U.S. Person
Part III Owner Information (File a separate report for each U.S. Owner that is a specified U.S. Person)
1 Name of owner
2 Number, street, and room or suite no. (if P.O. box, see instructions)
3a City or town 3b State, province, or region 3c Country, including postal code
4 TIN of owner
Part IV Financial Information
1 Account number 2 Currency code (see instructions)
3a Account balance
3b Check if account closed during the year (see instructions)
4a Interest
4b Dividends
4c Gross proceeds/Redemptions
4d Other
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 55748F
Form
8966 (2016)
Form 8966 (2016)
Page 2
Part V Pooled Reporting Type
1 Check applicable pooled reporting type (check only one):
Recalcitrant account holders with U.S. Indicia
Dormant accounts
Recalcitrant account holders that are U.S. persons
Recalcitrant account holders without U.S. Indicia
Non-participating FFI
Recalcitrant account holders that are passive NFFEs
2 Number of accounts 3 Aggregate payment amount
4 Aggregate account balance 5 Currency code
Form
8966 (2016)
