OMB No. 1545-2246
Form 8966                                                                FATCA Report
Department of the Treasury  
Internal Revenue Service            Go to www.irs.gov/Form8966 for instructions and the latest information.                                   2023
If you are filing paper Forms 8966, enter the three-digit identifier number used to identify this Form 8966 filing 
(see instructions)  .    .  . . .   . . .           . .   . . .          . . .     . . .  .  .  . . .   .      . . .      .         . . .   . .  
Check if report is being corrected, amended, voided, or there are no accounts to report:
   Corrected report                 Amended report                       Voided report         Check if no accounts to report (see instructions)
Part I       Identification of Filer
1a  Name of filer                                                                    1b  Enter the filer category (see instructions)

2  Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                    3b  State, province, or region                  3c  Country, including postal code 

4  Global intermediary identification number (GIIN)                                    5  TIN
                            .                         .                 .
6  Name of sponsored entity or intermediary, if applicable

7  Number, street, and room or suite no. (if P.O. box, see instructions)

8a  City or town                                    8b  State, province, or region                  8c  Country, including postal code 

9  GIIN                                                                                10  TIN
                            .                         .                 .
Part II      Account Holder or Payee Information
1a  Name of account holder or payee                                                                 1b  Indicate whether account holder or payee is an individual or entity
                                                                                                          Individual                  Entity
2  Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                    3b  State, province, or region                  3c  Country, including postal code 

4  TIN

5  If account holder or payee is an entity, check applicable box to specify the entity type:
   Owner-Documented FFI with specified U.S. Owner(s)                                      Passive NFFE with substantial U.S. Owner(s)
   Non-Participating FFI                                                                  Specified U.S. Person
Part III     Owner Information (File a separate report for each U.S. Owner that is a specified U.S. Person.)
1  Name of owner

2  Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                    3b  State, province, or region                  3c  Country, including postal code 

4  TIN of owner

Part IV       Financial Information
1  Account number                                                                      2  Currency code (see instructions)

3a  Account balance
                                                                                       3b  Check if account closed during the year (see instructions)  . . .
4a  Interest                                                                           4c  Gross proceeds/Redemptions

4b  Dividends                                                                          4d  Other

For Paperwork Reduction Act Notice, see separate instructions.                                    Cat. No. 55748F                                Form 8966 (2023) 

Form 8966 (2023)                                                                                                      Page 2 
Part V Pooled Reporting Type
1  Check applicable pooled reporting type (check only one):
   Recalcitrant account holders with U.S. Indicia             Recalcitrant account holders without U.S. Indicia
   Dormant accounts                                           Non-Participating FFI
   Recalcitrant account holders that are U.S. Persons         Recalcitrant account holders that are passive NFFEs
2  Number of accounts                                      3  Aggregate payment amount
4  Aggregate account balance                               5  Currency code

                                                                                                                 Form 8966 (2023)