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Form 8938 (December 2013) Department of the Treasury Internal Revenue Service Statement of Specified Foreign Financial Assets a Information about Form 8938 and its separate instructions is at www.irs.gov/form8938 . a Attach to your tax return. OMB No. 1545-2195 Attachment Sequence No. 175 If you have attached continuation statements, check here Number of continuation statements Name(s) shown on return Identifying number Part I Foreign Deposit and Custodial Accounts Summary 1 Number of Deposit Accounts (reported on Form 8938) ................ a 2 Maximum Value of All Deposit Accounts ..................... $ 3 Number of Custodial Accounts (reported on Form 8938) ............... a 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) ................. a 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. (1) Foreign currency in which account is maintained (2) Foreign currency exchange rate used to convert to U.S. dollars (3) 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 (12-2013) ----------------Page (0) Break---------------- Form 8938 (12-2013) Page 2 Part V Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary (see instructions) (continued) 7 Name of financial institution in which account is maintained 8 Mailing address of financial institution in which account is maintained. Number, street, and room or suite no. 9 City or town Part VI Detailed Information for Each "Other Foreign Asset" Included in the Part II Summary (see instructions) Note. If you reported specified foreign financial assets on Forms 3520, 3520-A, 5471, 8621, 8865, or 8891, you do not have to include the assets on Form 8938. You must complete Part IV. See instructions. If you have more than one asset to report, attach a continuation statement for each additional asset (see instructions). 1 Description of asset 2 Identifying number or other designation 3 Complete all that apply. See instructions for reporting of multiple acquisition or disposition dates. a Date asset acquired during tax year, if applicable .................. b Date asset disposed of during tax year, if applicable ................. c Check if asset jointly owned with spouse d Check if no tax item reported in Part III with respect to this asset 4 Maximum value of asset during tax year (check box that applies) a $0 - $50,000 b $50,001 - $100,000 c $100,001 - $150,000 d $150,001 - $200,000 e If more than $200,000, list value ........................ $ 5 Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . . Yes No 6 If you answered “Yes” to line 5, complete all that apply. (1) Foreign currency in which asset is denominated (2) Foreign currency exchange rate used to convert to U.S. dollars (3) Source of exchange rate used if not from U.S. Treasury Financial Management Service 7 If asset reported on line 1 is stock of a foreign entity or an interest in a foreign entity, enter the following information fo r the asset. a Name of foreign entity b Type of foreign entity (1) Partnership (2) Corporation (3) Trust (4) Estate c Mailing address of foreign entity. Number, street, and room or suite no. d 8 If asset reported on line 1 is not stock of a foreign entity or an interest in a foreign entity, enter the following informatio n for the asset. Note. If this asset has more than one issuer or counterparty, attach a continuation statement with the same information for each additional issuer or counterparty (see instructions). a Name of issuer or counterparty Check if information is for Issuer Counterparty b Type of issuer or counterparty (1) Individual (2) Partnership (3) Corporation (4) Trust (5) Estate c Check if issuer or counterparty is a U.S. person Foreign person d Mailing address of issuer or counterparty. Number, street, and room or suite no. e Form 8938 (12-2013) State US Zip Code Foreign country name Foreign province Foreign postal code City or town State US Zip Code Foreign country name Foreign province Foreign postal code City or town State US Zip Code Foreign country name Foreign province Foreign postal code ----------------Page (1) Break----------------