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Form 8938 (Rev. 11-2021) Page 2
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 in Part V, attach a separate statement for each additional account. See instructions.
20 Type of account a Deposit 21 Account number or other designation
b Custodial
22 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
23 Maximum value of account during tax year . . . . . . . . . . . . . . . . . . . . . $
24 Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . . Yes No
25 If you answered “Yes” to line 24, complete all that apply.
(a) Foreign currency in which (b) Foreign currency exchange rate (c) Source of exchange rate used if not from U.S.
account is maintained used to convert to U.S. dollars Treasury Department’s Bureau of the Fiscal Service
26 a Name of financial institution in which account is maintained b Global Intermediary Identification Number (GIIN) (Optional)
. . .
27 Mailing address of financial institution in which account is maintained. Number, street, and room or suite no.
28 City or town, state or province, country, and ZIP or foreign postal code
Part VI Detailed Information for Each “Other Foreign Asset” Included in the Part II Summary (see instructions)
If you have more than one asset to report in Part VI, attach a separate statement for each additional asset. See instructions.
29 Description of asset 30 Identifying number or other designation
31 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
32 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 . . . . . . . . . . . . . . . . . . . . . . . . $
33 Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . . Yes No
34 If you answered “Yes” to line 33, complete all that apply.
(a) Foreign currency in which asset (b) Foreign currency exchange rate (c) Source of exchange rate used if not from U.S.
is denominated used to convert to U.S. dollars Treasury Department’s Bureau of the Fiscal Service
35 If asset reported on line 29 is stock of a foreign entity or an interest in a foreign entity, enter the following information for the asset.
a Name of foreign entity b GIIN (Optional)
. . .
c Type of foreign entity (1) Partnership (2) Corporation (3) Trust (4) Estate
d Mailing address of foreign entity. Number, street, and room or suite no.
e City or town, state or province, country, and ZIP or foreign postal code
36 If asset reported on line 29 is not stock of a foreign entity or an interest in a foreign entity, enter the following information for
the asset.
Note: If this asset has more than one issuer or counterparty, attach a separate 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 City or town, state or province, country, and ZIP or foreign postal code
Form 8938 (Rev. 11-2021)
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