8938 Form 2013

Cat. No. 37753A Form 8938 12-2013 Page 2 Name of financial institution in which account is maintained Mailing address of financial institution in which account is maintained. Number street and room or suite no. 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 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. Were any foreign deposit or custodial accounts closed during the tax year Part II. Yes 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 c Amount reported on form or schedule No Summary of Tax Items Attributable to Specified Foreign Financial Assets see instructions a Asset Category Custodial Accounts Number of Foreign Assets reported on Form 8938. Attachment Sequence No* 175 Number of continuation statements Name s shown on return 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 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 attach a continuation statement for each additional account see instructions. Deposit Custodial 2 Account number or other designation Type of account 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 Did you use a foreign currency exchange rate to convert the value of the account into U*S* dollars. If you answered Yes to line 5 complete all that apply. 1 Foreign currency in which 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. City or town state or province and country including postal code 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. Description of asset 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. Check if asset jointly owned with spouse Check if no tax item reported in Part III with respect to this asset 0 - 50 000 50 001 - 100 000 100 001 - 150 000 e If more than 200 000 list value.