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 hereNumber of continuation statements Name(s) shown on returnIdentifying number Part IForeign Deposit and Custodial Accounts Summary 1Number of Deposit Accounts (reported on Form 8938) ................ a 2Maximum Value of All Deposit Accounts ..................... $ 3Number of Custodial Accounts (reported on Form 8938) ............... a 4Maximum Value of All Custodial Accounts ..................... $ 5Were any foreign deposit or custodial accounts closed during the tax year? ..........YesNo Part IIOther Foreign Assets Summary 1Number of Foreign Assets (reported on Form 8938) ................. a 2Maximum Value of All Assets ......................... $ 3Were any foreign assets acquired or sold during the tax year? ..............YesNo Part IIISummary 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 and1a Interest$ Custodial Accounts1b Dividends$ 1c Royalties$ 1d Other income$ 1e Gains (losses)$ 1f Deductions$ 1g Credits$ 2 Other Foreign Assets2a Interest$ 2b Dividends$ 2c Royalties$ 2d Other income$ 2e Gains (losses)$ 2f Deductions$ 2g Credits$ Part IVExcepted 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 35202. Number of Forms 3520-A3. Number of Forms 5471 4. Number of Forms 86215. Number of Forms 88656. Number of Forms 8891 Part VDetailed 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). 1Type of accountDepositCustodial2 Account number or other designation 3Check all that applyaAccount opened during tax yearbAccount closed during tax year cAccount jointly owned with spousedNo tax item reported in Part III with respect to this asset 4Maximum value of account during tax year ..................... $ 5Did you use a foreign currency exchange rate to convert the value of the account into U.S. dollars? . .YesNo 6If 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. 37753AForm 8938 (12-2013) ----------------Page (0) Break---------------- Form 8938 (12-2013)Page 2 Part VDetailed 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 VIDetailed 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 asset2 Identifying number or other designation 3Complete all that apply. See instructions for reporting of multiple acquisition or disposition dates. aDate asset acquired during tax year, if applicable .................. bDate asset disposed of during tax year, if applicable ................. cCheck if asset jointly owned with spousedCheck if no tax item reported in Part III with respect to this asset 4Maximum value of asset during tax year (check box that applies) a$0 - $50,000b$50,001 - $100,000c$100,001 - $150,000d$150,001 - $200,000 eIf more than $200,000, list value ........................$ 5Did you use a foreign currency exchange rate to convert the value of the asset into U.S. dollars? . . .YesNo 6If 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 7If asset reported on line 1 is stock of a foreign entity or an interest in a foreign entity, enter the following information for the asset. aName of foreign entity bType of foreign entity(1)Partnership(2)Corporation(3)Trust(4)Estate cMailing 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 information 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). aName of issuer or counterparty Check if information is for IssuerCounterparty bType of issuer or counterparty (1)Individual(2)Partnership(3)Corporation(4)Trust(5)Estate cCheck if issuer or counterparty is aU.S. personForeign person dMailing address of issuer or counterparty. Number, street, and room or suite no. e Form 8938 (12-2013) StateUS Zip CodeForeign country nameForeign provinceForeign postal code City or townStateUS Zip CodeForeign country nameForeign provinceForeign postal code City or townStateUS Zip CodeForeign country nameForeign provinceForeign postal code ----------------Page (1) Break----------------