Form 8809-I
(November 2015)
Department of the Treasury
Internal Revenue Service
Application for Extension of Time
to File FATCA Form 8966
Information about Form 8809-I and its separate instructions is at
OMB No. 1545-2246
1 Name of filer
2 Number, street, and room or suite no. If a P.O. box, see instructions.
3a City or town 3b State, province, or region 3c Country (including postal code)
4 Filer global intermediary identification number (GIIN)
. . .
5 Taxpayer identification number (TIN)
6a Filer Point of Contact (POC) name 6b Filer POC email 6c Filer POC phone number
7 Name of sponsored entity or intermediary, if applicable
8 Number, street, and room or suite no. If a P.O. box, see instructions.
9a City or town 9b State, province, or region 9c Country (including postal code)
10 GIIN of sponsored entity or intermediary
. . .
11 TIN
12 Check your method of filing Form 896
6 . .
Electronic Paper
Check this box only if you already requested the automatic extension and you now need an additional extension. See instructions . . . . .
If you checked the box on line 13, state in detail why you need an additional extension of time. You must provide sufficient cause as to why you
were not able to file by the date granted by the first extension request. If you need more space, attach additional sheets. Include the filer name,
TIN, and GIIN on each additional page.
Under penalties of perjury, I declare that I have examined this form, including any accompanying statements, and, to the best of my knowledge and belief, it is true, correct,
and complete.
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 67371G
Form 8809-I (11-2015)
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