Form 8957
(Rev. June 2018)
Department of the Treasury
Internal Revenue Service
Foreign Account Tax Compliance Act (FATCA) Registration
Go to www.irs.gov/Form8957 for instructions and the latest information.
OMB No. 1545-2246
• All applicants must complete Part 1.
• This form will not be processed if it is not signed.
• DO NOT fill out this form if you have begun registering at www.irs.gov/FATCA.
The IRS strongly recommends that applicants register by accessing the online version of this form at www.irs.gov/FATCA. The use
of this paper form will take longer for the IRS to process and if any information is missing or incomplete the delay in registration
may be significant.
This form should be mailed to:
FATCA, Stop 6099 AUSC
3651 South IH 35
Austin, Texas 78741
Part 1
Financial Institution Registration
1 Select Financial Institution Type (check only one)
Single (not a member of an Expanded Affiliated Group)
Lead of an Expanded Affiliated Group
Member (not Lead) of an Expanded Affiliated Group. If a Member, you must provide the FATCA ID issued for such Member and provided
by your Lead:
Sponsoring Entity
2
Legal Name of the Financial Institution
3 a
What is the Financial Institution’s country/jurisdiction of residence for tax purposes?
b
What is the Financial Institution’s country/jurisdiction tax ID?
4 Select the Financial Institution’s FATCA classification in its country/jurisdiction of tax residence (check only one)
Direct Reporting NFFE
Participating FFI, including a Reporting Financial Institution under a Model 2 IGA
Registered Deemed-Compliant FFI that is a Local FFI
Registered Deemed-Compliant FFI that is a Non-Reporting Member of a PFFI Group
Registered Deemed-Compliant FFI that is a Qualified Collective Investment Vehicle
Registered Deemed-Compliant FFI that is a Qualified Credit Card Issuer or Servicer
Registered Deemed-Compliant FFI that is a Restricted Fund
Reporting Financial Institution under a Model 1 IGA
Sponsoring Entity of Sponsored Direct Reporting NFFEs
Sponsoring Entity of Sponsored FFIs
Sponsoring Entity of Sponsored FFIs and Sponsored Direct Reporting NFFEs
Trustee of a Trustee-Documented Trust
U.S. Financial Institution
5 Mailing Address of Financial Institution
Country/Jurisdiction
Address Line 1
Address Line 2
City State/Province/Region ZIP/Postal Code
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 37778V
Form 8957 (Rev. 6-2018)
Form 8957 (Rev. 6-2018)
Page 2
6 Indicate whether the Financial Institution has in effect a withholding agreement with the IRS to be treated as one of the following:
a
Qualified Intermediary (QI)
Provide QI EIN:
-
Does the Financial Institution intend to maintain its status as a QI?
Yes
No
b
Withholding Foreign Partnership (WP)
Provide WP EIN:
-
Does the Financial Institution intend to maintain its status as a WP?
Yes
No
c
Withholding Foreign Trust (WT)
Provide WT EIN:
-
Does the Financial Institution intend to maintain its status as a WT?
Yes
No
d
Not applicable
7 Does the Financial Institution maintain a branch in a jurisdiction outside of its country/jurisdiction of tax residence?
Yes (If “Yes,” complete lines 8 and 9)
No (If “No,” go to line 10)
8 Is the Financial Institution a tax resident of the United States or does it maintain a branch in the United States (other than the U.S.
territories)?
Yes Provide the U.S. EIN of the U.S. Financial Institution or U.S. branch:
-
No
9 List each jurisdiction (other than the United States) in which the Financial Institution maintains a branch. Also please list branches
maintained in any of the U.S. territories. If none, leave blank and go to line 10.
(Use additional sheets to add branches.)
10 FATCA Responsible Officer (RO) for the Financial Institution
Business Title of RO
Legal Name
Last (Family) First (Given) Middle
City
Country/Jurisdiction
Business Address Line 1
Business Address Line 2
State/Province/Region
ZIP/Postal Code
Business Telephone Number Business Fax Number Business Email Address of RO
Form 8957 (Rev. 6-2018)
Form 8957 (Rev. 6-2018)
Page 3
11a The Financial Institution’s RO will be a point of contact (POC) for the Financial Institution. In addition, the RO of a Financial Institution
registering as a Lead of all or part of an Expanded Affiliated Group will be a POC for each Member of that group.
Does the RO or an Authorizing Individual wish to designate one or more additional POCs for the Financial Institution?
Yes (If “Yes,” complete line 11b)
No (If “No,” go to line 12)
b This line 11b must be completed by the Financial Institution’s RO or an Authorizing Individual. Upon entering the POC information
below, checking the box that follows, and submitting this registration form, the RO or Authorizing Individual is providing the IRS with
written authorization to release FATCA information to the POC. This authorization specifically includes authorization for the POC to
complete this Form 8957: FATCA Registration, to take other FATCA-related actions, and to obtain access to the Financial Institution’s
tax information.
Business Title of POC
Legal Name of POC
Last (Family) First (Given) Middle
City
Country/Jurisdiction
Business Address Line 1
Business Address Line 2 State/Province/Region ZIP/Postal Code
Business Telephone Number Business Fax Number Business Email Address of POC
Five POCs are allowed per Financial Institution. Use additional sheets to add POCs.
By checking this box, I, , as RO or Authorizing Individual for the Financial Institution, provide the authorization
described above to the identified POCs listed on this line 11b. Once this authorization is granted, it is effective until revoked by either
the Financial Institution or the POC.
Part 2
Expanded Affiliated Group
Lead Financial Institutions must read the instructions before completing Part 2.
12 Provide the following for each Financial Institution Member of the Expanded Affiliated Group
Legal name of Member Financial Institution
Country/Jurisdiction of residence for tax
purposes
Member type *
* Enter the FATCA Classification type from line 4 above for each Member Financial Institution. See the instructions for additional information.
Form 8957 (Rev. 6-2018)
Form 8957 (Rev. 6-2018)
Page 4
Part 2
Expanded Affiliated Group (continued)
13a Is the Financial Institution the Common Parent Entity of the Expanded Affiliated Group?
Yes (If “Yes,” go to Signature line)
No (If “No,” complete line 13b)
b Enter the Legal Name of the Expanded Affiliated Group’s Common Parent Entity. Also enter the FATCA ID (if known).
Legal Name of the Common Parent Entity
FATCA ID
SIGNATURE
By checking this box, I, , certify that, to the best of my knowledge, the information submitted above is accurate and
complete and I am authorized to agree that the Financial Institution (including its branches, if any) will comply with its FATCA obligations in
accordance with the terms and conditions reflected in regulations, intergovernmental agreements, and other administrative guidance to the
extent applicable to the Financial Institution based on its status in each jurisdiction in which it operates.
Sign
Here
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.
Signature
Date
Form 8957 (Rev. 6-2018)
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