DO NOT STAPLE

Form   8966-C
(Rev. December 2016)                 Cover Sheet for Form 8966 Paper Submissions                                                         OMB No. 1545-2246
Department of the Treasury 
Internal Revenue Service
Name of filer

Taxpayer Identification Number (TIN)                                           Global Intermediary Identification Number (GIIN)
                                                                                        .                                      .             .
Number, street, and room or suite no.

City or town, state or province, country, and ZIP or foreign postal code 

1      Type of paper Forms 8966 attached (check only one box):                 Original   Amended                              Corrected           Voided

2      Number of paper Forms 8966 attached ▶

Caution: Please ensure only one box is checked on line 1. If this transmittal is submitting corrected, amended, or voided 
reports, please ensure all attached Forms 8966 submitted under this cover sheet are correctly marked and consistent 
with the box checked on line 1.

                           Please return this entire page to the Internal Revenue Service.
       I  declare  that  I  have  examined  this  return  and  accompanying  documents  and,  to  the  best  of  my  knowledge  and  belief,  they  are  true, 
Sign   correct, and complete.
       Your▲ signature                                                   Title            Date                                 Daytime phone number
Here

Instructions                                                                   Identifying information at top of form. The identifying 
                                                                               information of the filer named on this form must be the same as 
Purpose of form. Use this form to transmit paper Forms 8966,                   the information entered on Forms 8966. If you have been 
FATCA Report, to the Internal Revenue Service. Use a separate                  assigned a GIIN by the IRS, enter that number on the line for 
Form 8966-C to transmit each type of Form 8966 (see the                        GIIN. If you do not have a GIIN, enter your EIN on the line for 
instructions for line 1).                                                      TIN.
Electronic filing requirement. Unless you have a hardship                      Line 1. Check the box for the type of paper Forms 8966 
waiver, you must file Forms 8966 electronically. If you submit                 (original, amended, corrected, or voided) you are transmitting. 
Forms 8966 electronically, do not use Form 8966-C.                             Check only one box. Each type must be transmitted with a 
Where and when to file. Send Form 8966-C (and the paper                        separate Form 8966-C. See the Instructions for Form 8966 for 
Forms 8966 being transmitted) to:                                              when to file an amended, corrected, or voided Form 8966.
Internal Revenue Service                                                       Line 2. Enter the number of paper Forms 8966 attached to the 
FATCA, Stop 6052 AUSC                                                          Form 8966-C. Please ensure all attached Forms 8966 submitted 
3651 South IH 35                                                               under this cover sheet are correctly marked and consistent with 
Austin, Texas 78741                                                            the box checked on line 1.
Send Form 8966-C and paper Forms 8966 by the due date                          Paperwork Reduction Act Notice. The time needed to 
specified in the instructions for Form 8966.                                   complete and file this form will vary depending on individual 
                                                                               circumstances. The estimated average time is 7 minutes.

For Paperwork Reduction Act Notice, see Form 8966.                                      Cat. No. 67369U                          Form 8966-C (Rev. 12-2016)