Form 3520-A (2019)
Page 5
2019 Foreign Grantor Trust Beneficiary Statement
Important: Trustee must prepare a separate statement for each U.S. beneficiary that received a distribution from the trust during the tax year and
include a copy of each statement with Form 3520-A. Trustee is also required to send to each such beneficiary a copy of the beneficiary’s
statement. Each U.S. beneficiary must attach a copy of its statement to its Form 3520.
1a Name of foreign trust b(1) Employer identification number
b(2)
Reference ID number (see instructions)
c Number, street, and room or suite no. (if a P.O. box, see instructions)
d City or town e State or province f
ZIP or foreign postal code
g Country
2
Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If “Yes,” complete lines 3a through 3g.
If “No,” do you agree that either the IRS or the U.S. beneficiary can inspect and copy the trust’s permanent books of
account, records, and such other documents that are necessary to establish that the trust should be treated for U.S.
tax purposes as owned by another person? . . . . . . . . . . . . . . . . . . . . . .
Yes No
3a Name of U.S. agent b Identification number
c Number, street, and room or suite no. (if a P.O. box, see instructions)
d City or town e State or province f ZIP or postal code g Country
4a Name of trustee b Identification number (if any)
c Number, street, and room or suite no. (if a P.O. box, see instructions)
d City or town e State or province f ZIP or postal code g Country
5 The first and last day of the tax year of the foreign trust to which Form 3520-A applies
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6a Name of U.S. beneficiary b Identification number
c Number, street, and room or suite no. (if a P.O. box, see instructions)
d City or town e State or province f ZIP or postal code g Country
7
Cash amounts or FMV of property that during the current tax year was: (1) distributed directly or indirectly to a U.S. person whether or not the
U.S. person is designated as a beneficiary of the trust, (2) loaned (exclude loans treated as qualified obligations) directly or indirectly to the
U.S. person who is a beneficiary of the trust or a U.S. person related to that U.S. person, or (3) used by the U.S. person who is a beneficiary of
the trust or a U.S. person related to that U.S. person without compensating the trust for the FMV of the use of the property within a reasonable
period of time. (See the instructions for Part III of Form 3520 for U.S. tax treatment of these amounts).
(a)
Date of distribution
(b)
Description of property distributed
(c)
FMV of property distributed
(determined on date of distribution)
(d)
Description of property
transferred, if any
(e)
FMV of property
transferred
(f)
Excess of column (c)
over column (e)
Totals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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$
8
Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion
of the foreign trust) is treated for U.S. tax principles as owned by another person.
9 Owner of the foreign trust is (check one):
Individual Partnership Corporation
Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge and
belief, it is true, correct, and complete.
Trustee Signature
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Title
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Date
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Form 3520-A (2019)