Form 8938 Statement of Specified Foreign Financial Assets

8938

Form
(December 2013)

Department of the Treasury
Internal Revenue Service

Statement of Specified Foreign Financial Assets
▶

Information about Form 8938 and its separate instructions is at www.irs.gov/form8938.
▶ Attach to your tax return.

If you have attached continuation statements, check here

1
2
3
4
5
1
2
3

Identifying number

Foreign Deposit and Custodial Accounts Summary

Number of Deposit Accounts (reported on Form 8938) . . . . . . .
Maximum Value of All Deposit Accounts
. . . . . . . . . . .
Number of Custodial Accounts (reported on Form 8938) . . . . . .
Maximum Value of All Custodial Accounts . . . . . . . . . . .
Were any foreign deposit or custodial accounts closed during the tax year?

Part II

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2 Other Foreign Assets

1a
1b
1c
1d
1e
1f
1g
2a
2b
2c
2d
2e
2f
2g

(b) Tax item
Interest
Dividends
Royalties
Other income
Gains (losses)
Deductions
Credits
Interest
Dividends
Royalties
Other income
Gains (losses)
Deductions
Credits

(c) Amount reported on
form or schedule

Yes

No

Yes

No

$

Summary of Tax Items Attributable to Specified Foreign Financial Assets (see instructions)

(a) Asset Category
1 Foreign Deposit and
Custodial Accounts

Part IV

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Other Foreign Assets Summary

Number of Foreign Assets (reported on Form 8938) . . . .
Maximum Value of All Assets . . . . . . . . . . .
Were any foreign assets acquired or sold during the tax year?

Part III

Attachment
Sequence No. 175

Number of continuation statements

Name(s) shown on return

Part I

OMB No. 1545-2195

Where reported
(d) Form and line
(e) Schedule and line

$
$
$
$
$
$
$
$
$
$
$
$
$
$

Excepted Specified Foreign Financial Assets (see instructions)

If you reported specified foreign financial assets on one or more of the following forms, enter the number of such forms filed. You do
not need to include these assets on Form 8938 for the tax year.
1. Number of Forms 3520
4. Number of Forms 8621

Part V

2. Number of Forms 3520-A
5. Number of Forms 8865

3. Number of Forms 5471
6. Number of Forms 8891

Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions)

If you have more than one account to report, attach a continuation statement for each additional account (see instructions).
Deposit
Custodial
2 Account number or other designation
Type of account
1
3
4
5
6

Account opened during tax year
b
Account closed during tax year
a
c
d
No tax item reported in Part III with respect to this asset
Account jointly owned with spouse
Maximum value of account during tax year . . . . . . . . . . . . . . . . . . . . . $
Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . .
Yes
No
If you answered “Yes” to line 5, complete all that apply.
(1) Foreign currency in which
(2) Foreign currency exchange rate used to (3) Source of exchange rate used if not from
account is maintained
convert to U.S. dollars
U.S. Treasury Financial Management Service
Check all that apply

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 37753A

Form 8938 (12-2013)

Page 2

Form 8938 (12-2013)

Part V

Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions) (continued)

7

Name of financial institution in which account is maintained

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 VI

Detailed Information for Each "Other Foreign Asset" Included in the Part II Summary (see instructions)

Note. If you reported specified foreign financial assets on Forms 3520, 3520-A, 5471, 8621, 8865, or 8891, you do not have to include
the assets on Form 8938. You must complete Part IV. See instructions.
If you have more than one asset to report, attach a continuation statement for each additional asset (see instructions).
2 Identifying number or other designation
Description of asset
1
3

Complete 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 spouse
d
Check if no tax item reported in Part III with respect to this asset
4
Maximum value of asset during tax year (check box that applies)
a
$0 - $50,000
b
$50,001 - $100,000
c
$100,001 - $150,000
d
$150,001 - $200,000
e If more than $200,000, list value . . . . . . . . . . . . . . . . . . . . . . . . $
5
Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . .
Yes
No
6
If you answered “Yes” to line 5, complete all that apply.
(1) Foreign currency in which asset (2) Foreign currency exchange rate used to (3) Source of exchange rate used if not from
is denominated
convert to U.S. dollars
U.S. Treasury Financial Management 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 entity
Partnership
(2)
Corporation
(3)
Trust
(4)
Estate
b Type of foreign entity
(1)
c Mailing address of foreign entity. Number, street, and room or suite no.
d 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.
Note. If this asset has more than one issuer or counterparty, attach a continuation statement with the same information for each
additional issuer or counterparty (see instructions).

a

Name of issuer or counterparty
Check if information is for

b Type of issuer or counterparty
(1)
Individual

Issuer

(2)

Partnership

Counterparty

(3)

Corporation

(4)

Trust

(5)

Estate

U.S. person
Foreign person
c Check if issuer or counterparty is a
d Mailing address of issuer or counterparty. Number, street, and room or suite no.
e

City or town, state or province, and country (including postal code)
Form

8938

(12-2013)

Page

Form 8938 (12-2013)

(Continuation Statement)
Name(s) shown on return

Part V

Identifying number

Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary
(see instructions)
Deposit

2 Account number or other designation

Custodial

1

Type of account

3
4
5
6

Account opened during tax year
b
Account closed during tax year
a
c
d
No tax item reported in Part III with respect to this asset
Account jointly owned with spouse
Maximum value of account during tax year . . . . . . . . . . . . . . . . . . . . . $
Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . .
Yes
No
If you answered “Yes” to line 5, complete all that apply.
(1) Foreign currency in which
(2) Foreign currency exchange rate used to (3) Source of exchange rate used if not from
account is maintained
convert to U.S. dollars
U.S. Treasury Financial Management Service

7

Name of financial institution in which account is maintained

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)

Check all that apply

Part VI

Detailed Information for Each "Other Foreign Asset" Included in the Part II Summary (see instructions)
2 Identifying number or other designation

Description of asset

1
3

Complete 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 spouse
d
Check if no tax item reported in Part III with respect to this asset
4
Maximum value of asset during tax year (check box that applies)
a
$0 - $50,000
b
$50,001 - $100,000
c
$100,001 - $150,000
d
$150,001 - $200,000
e If more than $200,000, list value . . . . . . . . . . . . . . . . . . . . . . . . $
5
Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . .
Yes
No
6
If you answered “Yes” to line 5, complete all that apply.
(1) Foreign currency in which asset (2) Foreign currency exchange rate used to (3) Source of exchange rate used if not from
is denominated
convert to U.S. dollars
U.S. Treasury Financial Management 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 entity
Partnership
(2)
Corporation
(3)
Trust
(4)
Estate
b Type of foreign entity
(1)
c Mailing address of foreign entity. Number, street, and room or suite no.
d 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

b Type of issuer or counterparty
(1)
Individual

Issuer

(2)

Partnership

Counterparty

(3)

Corporation

(4)

Trust

(5)

Estate

U.S. person
Foreign person
c Check if issuer or counterparty is a
d Mailing address of issuer or counterparty. Number, street, and room or suite no.
e

City or town, state or province, and country (including postal code)
Form

8938

(12-2013)