Form 8938 Statement of Specified Foreign Financial Assets

8938

Statement of Specified Foreign Financial Assets

Form
▶ Go to www.irs.gov/Form8938 for instructions and the latest information.
(Rev. November 2021)
▶ Attach to your tax return.
Department of the Treasury
For calendar year 20
or tax year beginning
, 20
, and ending
Internal Revenue Service

If you have attached additional statements, check here

OMB No. 1545-2195
Attachment
Sequence No. 938

, 20

Number of additional statements

1

Name(s) shown on return

3

Type of filer
Specified individual
b
Partnership
c
Corporation
d
Trust
a
If you checked box 3a, skip this line 4. If you checked box 3b or 3c, enter the name and TIN of the specified individual who
closely holds the partnership or corporation. If you checked box 3d, enter the name and TIN of the specified person who is a
current beneficiary of the trust. (See instructions for definitions and what to do if you have more than one specified individual or
specified person to list.)
a Name
b TIN

4

Part I
5
6
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8
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Yes

No

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Yes

No

$

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

(a) Asset category
13 Foreign deposit and
custodial accounts

14 Other foreign assets

Part IV

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Other Foreign Assets Summary

Number of foreign assets (reported in Part Vl) . . . . . .
Maximum value of all assets (reported in Part Vl) . . . . .
Were any foreign assets acquired or sold during the tax year?

Part III

Taxpayer identification number (TIN)

Foreign Deposit and Custodial Accounts Summary

Number of deposit accounts (reported in Part V) . . . . . . . . .
Maximum value of all deposit accounts . . . . . . . . . . . .
Number of custodial accounts (reported in Part V) . . . . . . . .
Maximum value of all custodial accounts . . . . . . . . . . .
Were any foreign deposit or custodial accounts closed during the tax year?

Part II
10
11
12

2

(b) Tax item
a
b
c
d
e
f
g
a
b
c
d
e
f
g

Interest
Dividends
Royalties
Other income
Gains (losses)
Deductions
Credits
Interest
Dividends
Royalties
Other income
Gains (losses)
Deductions
Credits

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

(c) Amount reported on
form or schedule
$
$
$
$
$
$
$
$
$
$
$
$
$
$

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.
15 Number of Forms 3520
16 Number of Forms 3520-A
17 Number of Forms 5471
18 Number of Forms 8621
19 Number of Forms 8865
For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 37753A

Form 8938 (Rev. 11-2021)

Page 2

Form 8938 (Rev. 11-2021)

Part V

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 in Part V, attach a separate statement for each additional account. See instructions.
Deposit
21 Account number or other designation
20
Type of account
a
b
Custodial
Account opened during tax year
b
Account closed during tax year
22
Check all that apply
a
Account jointly owned with spouse
d
No tax item reported in Part III with respect to this asset
c
23
Maximum value of account during tax year . . . . . . . . . . . . . . . . . . . . . $
24
Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . .
Yes
No
25
If you answered “Yes” to line 24, complete all that apply.
(a) Foreign currency in which
(b) Foreign currency exchange rate (c) Source of exchange rate used if not from U.S.
account is maintained
used to convert to U.S. dollars
Treasury Department’s Bureau of the Fiscal Service

27

b Global Intermediary Identification Number (GIIN) (Optional)
.
.
.
Mailing address of financial institution in which account is maintained. Number, street, and room or suite no.

28

City or town, state or province, country, and ZIP or foreign postal code

26a

Name of financial institution in which account is maintained

Part VI

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

If you have more than one asset to report in Part VI, attach a separate statement for each additional asset. See instructions.
30 Identifying number or other designation
Description of asset
29
31
a
b
c
32
a
e
33
34

Complete all that apply. See instructions for reporting of multiple acquisition or disposition dates.
Date asset acquired during tax year, if applicable . . . . . . . . . . . . . . . . . .
Date asset disposed of during tax year, if applicable . . . . . . . . . . . . . . . . .
Check if asset jointly owned with spouse
d
Check if no tax item reported in Part III with respect to this asset
Maximum value of asset during tax year (check box that applies)
$0–$50,000
b
$50,001–$100,000
c
$100,001–$150,000
d
$150,001–$200,000
If more than $200,000, list value . . . . . . . . . . . . . . . . . . . . . . . . $
Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . .
Yes
No
If you answered “Yes” to line 33, complete all that apply.
(a) Foreign currency in which asset (b) Foreign currency exchange rate (c) Source of exchange rate used if not from U.S.
is denominated
used to convert to U.S. dollars
Treasury Department’s Bureau of the Fiscal Service

35

If asset reported on line 29 is stock of a foreign entity or an interest in a foreign entity, enter the following information for the asset.
Name of foreign entity
b GIIN (Optional)
.
.
.
c Type of foreign entity
(1)
Partnership
(2)
Corporation
(3)
Trust
(4)
Estate
d Mailing address of foreign entity. Number, street, and room or suite no.
a

e

City or town, state or province, country, and ZIP or foreign postal code

36

If asset reported on line 29 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 separate statement with the same information for each
additional issuer or counterparty. See instructions.
a Name of issuer or counterparty
Check if information is for
Issuer
Counterparty
b Type of issuer or counterparty
Individual
(2)
Partnership
(3)
Corporation
(4)
Trust
(5)
Estate
(1)
c Check if issuer or counterparty is a
U.S. person
Foreign person
d Mailing address of issuer or counterparty. Number, street, and room or suite no.
e

City or town, state or province, country, and ZIP or foreign postal code
Form 8938 (Rev. 11-2021)