Foreign Account Worksheet
A separate Worksheet must be filled out
for each foreign account.
PERSONAL DATA
(Please Print)
First Name M.I. Last Name (as on your SS Card) Phone Number Email Address
Taxpayer:
FOREIGN ACCOUNT INFORMATION
JOINT OWNER INFORMATION
Account is: check one Deposit Custodial
Type of Account:
Bank Securities Other specify:
Maximum Value of Account $
Account Number or other designation:
Account opened during the tax year? Yes No
Account closed during the tax year? Yes No
Taxable income with respect to this account? Yes No
Foreign Currency in which Account is Maintained:
Exchange Rate Used to Convert to US dollars:
Exchange Rate Source
(If not US Treasury Dept’s Bureau of the Fiscal Service)
Financial Institution in which account is held:
Address of Financial Institution City State Zip Code
Foreign Country Name Foreign Province/County Foreign Postal Code
Account is Owned Separately Jointly Owned with Spouse
Owned Jointly Authority but No Financial Interest
Number of Joint Owners:
Please provide the following information for each additional owner
Additional Owner’s Name First, Last and Middle Initial or organization name
Taxpayer Identification Number SSN/EIN/ITIN Foreign Identification Number
Address City State Zip Code
Foreign Country Name Foreign Province/County Foreign Postal Code
Additional Owner’s Name First, Last and Middle Initial or organization name
Taxpayer Identification Number SSN/EIN/ITIN Foreign Identification Number
Address City State Zip Code
Foreign Country Name Foreign Province/County Foreign Postal Code
