Annual Information Return of Foreign                                                          OMB No. 1545-0159
Form  3520-A                                                Trust With a U.S. Owner  
                                                                  (Under section 6048(b))
Department of the Treasury                                                                                                                  2021
Internal Revenue Service              ▶  Go to www.irs.gov/Form3520A for instructions and the latest information .
Note: All information must be in English. Show all amounts in U.S. dollars.
For calendar year 2021, or tax year beginning                                           , 2021, ending                                           , 20        .
Check appropriate boxes:           Initial return           Final return        Amended return   Extension filed                  Substitute Form 3520-A
Check if any excepted specified foreign financial assets are reported on this form. See instructions  .   .     . .     .  .    .  .      . .  . . .  .
Part I   General Information (see instructions)
1a    Name of foreign trust                                                                                            b   Employer identification number (EIN)

c    Number, street, and room or suite no. If a P.O. box, see instructions.                                            d   Date foreign trust was created

e    City or town                                    f    State or province             g   ZIP or foreign postal code h   Country

2        Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all the relevant 
         trust information?  . .   .   .    . .      .    . . .   . .    .    . .   . . . .  . . .     .  .     . .     .  .    .  .           Yes     No
         If “Yes,” skip lines 2a through 2e and go to line 3.
         If “No,” you are required to attach a copy of all trust documents as indicated below. If these documents have been attached to a Form 3520-A 
         filed within the previous 3 years, attach only relevant updates.
                                                                                                                                    Attached       Year 
         Are you attaching a copy of any of the following?                                                 Yes              No     Previously      Attached
a        Summary of all written and oral agreements and understandings relating to the trust  .  .     .
b        The trust instrument  .   .   .    . .      .    . . .   . .    .    . .   . . . .  . . .     .
c        Memoranda or letters of wishes .     .      .    . . .   . .    .    . .   . . . .  . . .     .
d        Subsequent variances to original trust documents  .        .    .    . .   . . . .  . . .     .
e        Organizational chart and other trust documents  .        . .    .    . .   . . . .  . . .     .
3a    Name of U.S. agent                                                                                               b   Taxpayer identification number (TIN)

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                                    e    State or province             f    ZIP or postal code        g   Country

4a    Name of trustee                                                                                                  b   TIN, if any

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                                    e    State or province             f    ZIP or postal code        g   Country

5        Enter the number of Foreign Grantor Trust Owner Statements (pages 3 and 4) included with this Form 3520-A .                ▶
6        Enter the number of Foreign Grantor Trust Beneficiary Statements (page 5) included with this Form 3520-A               .   ▶
         Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my 
Sign     knowledge▲ and belief, it is true, correct, and complete.          ▲                                                             ▲
Here
         Trustee’s (or U.S. owner’s) signature                                Title                                                         Date
         Print/Type preparer’s name                           Preparer’s signature             Date                    Check          if   PTIN
Paid                                                                                                                   self-employed
Preparer                    ▶                                                                                          Firm’s EIN ▶
         Firm’s name  
Use Only
         Firm’s address  ▶                                                                                             Phone no.
For Paperwork Reduction Act Notice, see instructions.                                     Cat. No. 19595G                                   Form 3520-A (2021)

Form 3520-A (2021)                                                                                                                          Page  2 
Part II         Foreign Trust Income Statement  
                Enter totals from books and records of foreign trust. See instructions.
           1  Interest    . . .   .     . .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        1
           2  Dividends  .  . .   .     . .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        2
           3  Gross rents and royalties   .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        3
           4  Income (loss) from partnerships and fiduciaries  .  .    .   . .   . . . . .     . . . . .            . . .        4
           5  Capital gains:
Income     a  Net short-term capital gain (loss)  .  .    . .   . .    .   . .   . . . . .     . . . . .            . . .        5a
           b  Net long-term capital gain (loss)    . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        5b
           6  Ordinary gains (losses)  .  .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        6
           7  Other income (attach statement)  .     .    . .   . .    .   . .   . . . . .     . . . . .            . . .        7
           8  Total income (add lines 1 through 7)  .     . .   . .    .   . .   . . . . .     . . . . .            . . .        8
           9  Interest expense  . .     . .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        9
         10a  Foreign taxes (attach statement)  .    .    . .   . .    .   . .   . . . . .     . . . . .            . . .        10a
           b  State and local taxes     . .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        10b
         11   Amortization and depreciation (depletion)     .   . .    .   . .   . . . . .     . . . . .            . . .        11
         12   Trustee and advisor fees    .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        12
         13
Expenses      Charitable contributions .  .  .     . .    . .   . .    .   . .   . . . . .     . . . . .            . . .        13
         14   Other expenses (attach statement)      .    . .   . .    .   . .   . . . . .     . . . . .            . . .        14
         15   Total expenses (add lines 9 through 14)  .    .   . .    .   . .   . . . . .     . . . . .            . . .        15
         16   Net income (loss) (subtract line 15 from line 8)  . .    .   . .   . . . . .     . . . . .            . . .        16
         17 a Enter the fair market value (FMV) of total distributions (directly or indirectly) from the trust to all persons, 
              whether U.S. or foreign. Attach statement. See instructions    .   . . . . .     . . . . .            . . . ▶      17a
           b  Distributions to U.S. owners:
                   (i) Name of owner                              (ii) TIN               (iii) Date of distribution         (iv) FMV on date of distribution

           c  Distributions to U.S. beneficiaries:
                (i) Name of beneficiary                           (ii) TIN               (iii) Date of distribution         (iv) FMV on date of distribution

Part III        Foreign Trust Balance Sheet                                Beginning of Tax Year                          End of Tax Year
                              Assets                                         (a)               (b)                      (c)              (d)
1          Cash .   .     . . .   .     . .  .     . .    . .
2          Accounts receivable .  .     . .  .     . .    . .
3          Mortgages and notes receivable    .     . .    . .
4          Inventories  . . . .   .     . .  .     . .    . .
5          Government obligations  .    . .  .     . .    . .
6          Other marketable securities  . .  .     . .    . .
7          Other nonmarketable securities .  .     . .    . .
8a         Depreciable (depletable) assets . .     . .    . .
         b Less: accumulated depreciation (depletion)  .    .
9          Real property  . . .   .     . .  .     . .    . .
10         Other assets (attach statement) . .     . .    . .
11         Total assets (add lines 1 through 7 and 8b through 10) 
                              Liabilities
12         Accounts payable . .   .     . .  .     . .    . .
13         Contributions, gifts, grants, etc., payable  . . .
14         Mortgages and notes payable  .    .     . .    . .
15         Other liabilities (attach statement)  . . .    . .  
16         Total liabilities (add lines 12 through 15)  . . .  
                              Net Worth
17         Contributions to trust corpus  .  .     . .    . .
18         Accumulated trust income  .    .  .     . .    . .
19         Other (attach statement) .   . .  .     . .    . .
20         Total net worth (add lines 17 through 19)  .   . .
21         Total liabilities and net worth (add lines 16 and 20)
                                                                                                                                    Form 3520-A (2021) 

Form 3520-A (2021)                                                                                                                                         Page  3 
                                    2021 Foreign Grantor Trust Owner Statement (see instructions)
Important: Trustee (or U.S. owner if a substitute Form 3520-A) must prepare a separate statement for each U.S. owner and include a copy of each 
            statement with Form 3520-A. Trustee is also required to send to each U.S. owner a copy of the owner’s statement. U.S. owner must attach 
            a copy of its statement to Form 3520.
1a    Name of foreign trust                                                                                             b    EIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.                                             d    Date foreign trust was created

e    City or town                              f   State or province                     g   ZIP or foreign postal code h    Country

2       Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust 
        information?   . .  .       . . .    . .   .     . . .       .  .  .    . .    . .    . . .        .  .  .      .  . .   .    . .        Yes       No
        If “Yes,” complete lines 3a through 3g.
3a    Name of U.S. agent                                                                                                b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                              e   State or province                     f   ZIP or postal code         g    Country

4a    Name of trustee                                                                                                   b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                              e   State or province                     f   ZIP or postal code         g    Country

5       The first and last day of the tax year of the foreign trust to which this statement relates  ▶
6a    Name of U.S. owner                                                                                                b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                              e   State or province                     f   ZIP or postal code         g    Country

7       Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion 
        of the foreign trust) is treated for U.S. tax principles as owned by the U.S. person.
8       If the trust did not appoint a U.S. agent, list the trust documents attached to Form 3520-A. See instructions.

9       Gross value of the portion of the trust treated as owned by the U.S. owner  .         . . .        .  .  .        $
10      Cash amounts or FMV of property distributed, directly or indirectly, during the foreign trust’s tax year, from the foreign trust (exclude loans) to 
        the U.S. owner.
        (a)                         (b)                                (c)                        (d)                        (e)                 (f) 
Date of distribution Description of property distributed   FMV of property distributed   Description of property   FMV of property        Excess of column (c)  
                                                         (determined on date of distribution) transferred, if any         transferred     over column (e)

Total . .   . .      . . .  .       . . .    . .   .     . . .       .  .  .    . .    . .    . . .        .  .  .      .  . .   .    ▶ $
                                                                                                                                          Form 3520-A (2021)

Form 3520-A (2021)                                                                                                                Page  4 
                   2021 Statement of Foreign Trust Income Attributable to U.S. Owner (see instructions)  
                                              Report each item on the proper form or schedule of your tax return.
         1a   Taxable interest  .   .     . . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   1a
           b  Tax-exempt interest  .      . . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   1b
         2a   Total ordinary dividends .    . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   2a
           b  Qualified dividends   ▶
         3    Gross rents and royalties     . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   3
Income   4    Income from partnerships and fiduciaries . . . .    . . .   . . . . . . . . . .                    . . .   4
         5    Capital gains (losses)      . . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   5
         6    Ordinary gains (losses)  .    . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   6
         7    Other income (attach statement)  .  . .    . . .    . . .   . . . . . . . . . .                    . . .   7
         8    Total income. Add lines 1a, 1b, 2a, and 3 through 7 . . .   . . . . . . . . . .                    . . . ▶ 8
         9    Interest expense  .   .     . . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   9
         10a  Foreign taxes (attach statement)  . . .    . . .    . . .   . . . . . . . . . .                    . . .   10a
           b  State and local taxes       . . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   10b
         11   Amortization and depreciation (depletion)  . . .    . . .   . . . . . . . . . .                    . . .   11
         12   Trustee and advisor fees      . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   12
         13
Expenses      Charitable contributions .    . . . . .    . . .    . . .   . . . . . . . . . .                    . . .   13
         14   Other expenses (attach statement)   . .    . . .    . . .   . . . . . . . . . .                    . . .   14
         15   Total expenses. Add lines 9 through 14  .  . . .    . . .   . . . . . . . . . .                    . . . ▶ 15
Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge and 
belief, it is true, correct, and complete.
Trustee’s (or 
U.S. owner’s) 
signature ▶                                                         Title ▶                                              Date ▶
                                                                                                                              Form 3520-A (2021)

Form 3520-A (2021)                                                                                                                                           Page  5 
                                                2021 Foreign Grantor Trust Beneficiary Statement
Important: Trustee (or U.S. owner if a substitute Form 3520-A) must prepare a separate statement for each U.S. beneficiary that received a distribution 
              from the trust during the tax year and include a copy of each statement with Form 3520-A. Trustee is also required to send to each such 
              beneficiary a copy of the beneficiary’s statement. Each U.S. beneficiary must attach a copy of its statement to its Form 3520.
1a    Name of foreign trust                                                                                             b    EIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.                                             d   Date foreign trust was created

e    City or town                                 f   State or province                  g   ZIP or foreign postal code h    Country

2       Did the foreign trust appoint a U.S. agent (defined in the instructions) who can provide the IRS with all relevant trust 
        information?      .  . .    .     .   . . .   .  . .   .     .  .   .   . .    . .    . . .        .  .  .      . .  .   .    . .      Yes           No
        If “Yes,” complete lines 3a through 3g.
        If “No,” do you agree that either the IRS or the U.S. beneficiary can inspect and copy the trust’s permanent books of 
        account, records, and such other documents that are necessary to establish that the trust should be treated for U.S. 
        tax purposes as owned by another person?  .        .   .     .  .   .   . .    . .    . . .        .  .  .      . .  .   .    . .      Yes           No
3a    Name of U.S. agent                                                                                                b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                                 e   State or province                  f   ZIP or postal code         g    Country

4a    Name of trustee                                                                                                   b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                                 e   State or province                  f   ZIP or postal code         g    Country

5       The first and last day of the tax year of the foreign trust to which Form 3520-A applies ▶
6a    Name of U.S. beneficiary                                                                                          b    TIN

c    Number, street, and room or suite no. If a P.O. box, see instructions.

d    City or town                                 e   State or province                  f   ZIP or postal code         g    Country

7       Cash amounts or FMV of property that during the current tax year was (1) distributed directly or indirectly to a U.S. person whether or not the 
        U.S. person is designated as a beneficiary of the trust, (2) loaned (exclude loans treated as qualified obligations) directly or indirectly to the 
        U.S. person who is a beneficiary of the trust or a U.S. person related to that U.S. person, or (3) used by the U.S. person who is a beneficiary of 
        the trust or a U.S. person related to that U.S. person without compensating the trust for the FMV of the use of the property within a reasonable 
        period of time. (See the instructions for Part III of Form 3520 for U.S. tax treatment of these amounts.)
        (a)                               (b)                          (c)                        (d)                        (e)                   (f) 
Date of distribution Description of property distributed   FMV of property distributed   Description of property   FMV of property         Excess of column (c)  
                                                         (determined on date of distribution) transferred, if any         transferred         over column (e)

Total .   .   . .    .    .  . .    .     .   . . .   .  . .   .     .  .   .   . .    . .    . . .        .  .  .      . .  .   .    ▶ $
8       Attach an explanation of the facts and law (including the section of the Internal Revenue Code) that establishes that the foreign trust (or portion 
        of the foreign trust) is treated for U.S. tax principles as owned by another person.
9       Owner of the foreign trust is (check one):           Individual             Partnership               Corporation
Under penalties of perjury, I declare that I have examined this return, including any accompanying reports, schedules, or statements, and to the best of my knowledge and 
belief, it is true, correct, and complete.
Trustee’s (or 
U.S. owner’s) 
signature ▶                                                                 Title ▶                                                      Date ▶
                                                                                                                                              Form 3520-A (2021)