Statement of Specified Foreign Financial Assets                                         OMB No. 1545-2195
Form  8938                       ▶ Go to www.irs.gov/Form8938 for instructions and the latest information. 
(Rev. November 2021)                                    ▶ Attach to your tax return.                                 Attachment  
Department of the Treasury  For calendar year 20 or tax year beginning       , 20     , and ending         , 20      Sequence No. 938
Internal Revenue Service 
     If you have attached additional statements, check here                    Number of additional statements
1       Name(s) shown on return                                                         2    Taxpayer identification number (TIN)

3      Type of filer
        a  Specified individual                  b    Partnership          c        Corporation         d    Trust
4      If you checked box 3a, skip this line 4. If you checked box 3b or 3c, enter the name and TIN of the specified individual who 
       closely holds the partnership or corporation. If you checked box 3d, enter the name and TIN of the specified person who is a 
       current beneficiary of the trust. (See instructions for definitions and what to do if you have more than one specified individual or 
       specified person to list.)
        a  Name                                                                                       b TIN
Part I     Foreign Deposit and Custodial Accounts Summary
5      Number of deposit accounts (reported in Part V)  .   .     .    . . . . .    . . . .     .  .  . .  . .   ▶
6      Maximum value of all deposit accounts  .       . . . .     .    . . . . .    . . . .     .  .  . .  . .   .  $
7      Number of custodial accounts (reported in Part V)    .     .    . . . . .    . . . .     .  .  . .  . .   ▶
8      Maximum value of all custodial accounts        . . . .     .    . . . . .    . . . .     .  .  . .  . .   .  $
9      Were any foreign deposit or custodial accounts closed during the tax year?  .    . .     .  .  . .  . .   .      Yes      No
Part II    Other Foreign Assets Summary
10     Number of foreign assets (reported in Part Vl)  .  . .     .    . . . . .    . . . .     .  .  . .  . .     ▶
11     Maximum value of all assets (reported in Part Vl)  . .     .    . . . . .    . . . .     .  .  . .  . .   .  $
12     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)
                                                            (c) Amount reported on                      Where reported
       (a) Asset     category      (b) Tax     item            form or schedule         (d) Form and line        (e) Schedule and line
13   Foreign deposit and          a   Interest            $
        custodial accounts        b   Dividends           $
                                  c   Royalties           $
                                  d   Other income        $
                                  e   Gains (losses)      $
                                  f   Deductions          $
                                  g   Credits             $
14   Other foreign assets         a   Interest            $
                                  b   Dividends           $
                                  c   Royalties           $
                                  d   Other income        $
                                  e   Gains (losses)      $
                                  f   Deductions          $
                                  g   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. 
15   Number of Forms 3520                          16   Number of Forms 3520-A                     17   Number of Forms 5471
18   Number of Forms 8621                          19   Number of Forms 8865
For Paperwork Reduction Act Notice, see the separate instructions.                    Cat. No. 37753A              Form 8938 (Rev. 11-2021)

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)