Form  
8938
(December 2013)
Department of the Treasury  
Internal Revenue Service 
Statement of Specified Foreign Financial Assets
a
 
Information about Form 8938 and its separate instructions is at 
www.irs.gov/form8938
.       
a
 
Attach to your tax return.
OMB No. 1545-2195
Attachment  
Sequence No.
 175 
If you have attached continuation statements, check here
Number of continuation statements
Name(s) shown on return
Identifying number
Part I
Foreign Deposit and Custodial Accounts Summary
1
Number of Deposit Accounts (reported on Form 8938) 
................  
a
2
Maximum Value of All Deposit Accounts 
.....................
 $
3
Number of Custodial Accounts (reported on Form 8938) 
...............  
a
4
Maximum Value of All Custodial Accounts 
.....................
 $
5
Were any foreign deposit or custodial accounts closed during the tax year? 
..........
Yes
No
Part II
Other Foreign Assets Summary
1
Number of Foreign Assets (reported on Form 8938) 
.................  
a
  
2
Maximum Value of All Assets 
.........................
 $
3
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)
(a)
 Asset Category
(b)
 Tax item
(c)
 Amount reported on 
form or schedule
Where reported
                                                                                                 
(d)
 Form and line
(
e)
 Schedule and line
   
1
  Foreign Deposit and
1a
  Interest
$
 Custodial Accounts
1b
  Dividends
$
     
1c
  Royalties
$
     
1d
  Other income
$
     
1e
  Gains (losses)
$
     
1f
   Deductions
$
      
1g
  Credits
$
 
 
2
  Other Foreign Assets
2a
  Interest
$
     
2b
  Dividends
$
     
2c
  Royalties
$
     
2d
  Other income
$
      
2e
  Gains (losses)
$
     
2f
   Deductions
$
     
2g
  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. 
1. Number of Forms 3520
2. Number of Forms 3520-A
3. Number of Forms 5471
4. Number of Forms 8621
5. Number of Forms 8865
6. Number of Forms 8891
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, attach a continuation statement for each additional account (see instructions).
1
Type of account
Deposit
Custodial
2
   Account number or other designation
3
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
4
Maximum value of account during tax year 
.....................
 $
5
Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars?   .    .
Yes
No
6
If you answered “Yes” to line 5, complete all that apply.
(1)  
Foreign currency in which 
account is maintained
(2)  
Foreign currency exchange rate used to 
convert to U.S. dollars
(3)  
Source of exchange rate used if not from 
U.S. Treasury Financial Management Service
For Paperwork Reduction Act Notice, see the separate instructions. 
Cat. No. 37753A
Form 
8938
  (12-2013) 
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Form 8938 (12-2013)
Page 
2 
Part V
Detailed Information for Each Foreign Deposit and Custodial Account Included in the Part I Summary 
(see instructions) (continued) 
7 
Name of financial institution in which account is maintained
8 
Mailing address of financial institution in which account is maintained. Number, street, and room or suite no.
9 
City or town
Part VI
Detailed Information for Each "Other Foreign Asset" Included in the Part II Summary 
(see instructions) 
Note.
 
If you reported specified foreign financial assets on Forms 3520, 3520-A, 5471, 8621, 8865, or 8891, you do not have to include
 
the assets on Form 8938. You must complete Part IV. See instructions.
If you have more than one asset to report, attach a continuation statement for each additional asset (see instructions).
1 
Description of asset
2  
Identifying number or other designation
3
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
4
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 
........................
$
5
Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars?  .    .    .
Yes
No
6
If you answered “Yes” to line 5, complete all that apply.
(1)  
Foreign currency in which asset 
is denominated
(2)  
Foreign currency exchange rate used to 
convert to U.S. dollars
(3)  
Source of exchange rate used if not from 
U.S. Treasury Financial Management Service
7
If asset reported on line 1 is stock of a foreign entity or an interest in a foreign entity, enter the following information fo
r the asset.
a
Name of foreign entity
b
Type of foreign entity
(1)
Partnership
(2)
Corporation
(3)
Trust
(4)
Estate
c
Mailing address of foreign entity. Number, street, and room or suite no.
d
8 
 
If asset reported on line 1 is not stock of a foreign entity or an interest in a foreign entity, enter the following informatio
n for the 
asset.
Note.
 
If this asset has more than one issuer or counterparty, attach a continuation 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
Form  
8938 
 (12-2013)
State
US Zip Code
Foreign country name
Foreign province
Foreign postal code
City or town
State
US Zip Code
Foreign country name
Foreign province
Foreign postal code
City or town
State
US Zip Code
Foreign country name
Foreign province
Foreign postal code
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