Form 8938 - Statement of Foreign Financial Assets (2014)
Form 8938
(Rev. December 2014)
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.
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Attach to your tax return.
OMB No. 1545-2195
Attachment
Sequence No. 175
For calendar year 20
or tax year beginning
, 20 and ending , 20
If you have attached continuation statements, check here Number of continuation statements
Name(s) shown on return TIN
Part I Foreign Deposit and Custodial Accounts Summary
1
Number of Deposit Accounts (reported on Form 8938) . . . . . . . . . . . . . . . .
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2
Maximum Value of All Deposit Accounts . . . . . . . . . . . . . . . . . . . . . $
3
Number of Custodial Accounts (reported on Form 8938) . . . . . . . . . . . . . . .
▶
4 Maximum Value of All Custodial Accounts . . . . . . . . . . . . . . . . . . . . . $
5 Were any foreign deposit or custodial accounts closed during the tax year? . . . . . . . . . .
Yes No
Part II Other Foreign Assets Summary
1
Number of Foreign Assets (reported on Form 8938) . . . . . . . . . . . . . . . . .
▶
2 Maximum Value of All Assets . . . . . . . . . . . . . . . . . . . . . . . . . $
3 Were any foreign assets acquired or sold during the tax year? . . . . . . . . . . . . . .
Yes No
Part III Summary of Tax Items Attributable to Specified Foreign Financial Assets (see instructions)
(a) Asset Category (b) Tax item
(c) Amount reported on
form or schedule
Where reported
(d) Form and line (e) Schedule and line
1 Foreign Deposit and
1a Interest $
Custodial Accounts 1b Dividends $
1c Royalties $
1d Other income $
1e Gains (losses) $
1f Deductions $
1g Credits $
2 Other Foreign Assets 2a Interest $
2b Dividends $
2c Royalties $
2d Other income $
2e Gains (losses) $
2f Deductions $
2g Credits $
Part IV 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 2. Number of Forms 3520-A 3. Number of Forms 5471
4. Number of Forms 8621 5. Number of Forms 8865 6. Number of Forms 8891
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).
1
Type of account
Deposit Custodial
2 Account number or other designation
3 Check all that apply a
Account opened during tax year b Account closed during tax year
c
Account jointly owned with spouse
d
No tax item reported in Part III with respect to this asset
4 Maximum value of account during tax year . . . . . . . . . . . . . . . . . . . . . $
5 Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . .
Yes No
6 If you answered “Yes” to line 5, complete all that apply.
(a) Foreign currency in which
account is maintained
(b) Foreign currency exchange rate used to
convert to U.S. dollars
(c) Source of exchange rate used if not from
U.S. Treasury Financial Management Service
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 37753A
Form
8938 (Rev. 12-2014)
Page 1/3
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