4. FATCA
Foreign Account Tax Compliant Act.
At any time during the year, did you have a financial interest in or signature authority over a financial account (such as a bank account, securities account, or brokerage account) located in a foreign country (non-USA)?
YesNo
If yes, which countries (list all countries):
Is the sum of the highest balances of your foreign financial assets greater than USD$10,000?
Do you need US Global Tax Limited to prepare and file your FinCEN 114 (FBAR)?
Is the sum of the highest balances of your foreign financial assets greater than USD$200,000?
5. Trusts
Are you a Settlor, Trustee, or Beneficiary of a foreign trust (non-US)?
During the year, did you receive a distribution from, or transfered property/cash to a foreign trust (non-USA)?
If you (or your spouse if filing jointly) have a beneficial interest in a trust, (settler, trustee or beneficiary), please list these below
Name of trust:
Person with relationship:
Are you a beneficiary / settlor / trustee:
Date established:
6. Pension/Superannuation
(applicable to Australian residents)
Do you have a superannuation fund?
Of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
If you or your spouse have a self-managed super fund (SMSF), please state the year the fund was formed:
Fund 2
Of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
Fund 3
Of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
7. Pension/Superannuation
(applicable to New Zealand residents)
Do you have a KiwiSaver or Superannuation Account?
If so, of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
Estimated value as at 31st December last year:
Fund 2
Of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
Estimated value as at 31st December last year:
Fund 3
Of the total contributions to the account, do your contributions (as opposed to Govt. and Employer contributions) make up the majority of the total contributions value?
Estimated value as at 31st December last year:
8. Capital Gains
Please list any capital gains or losses you (or your spouse if filing jointly) have from any sale or disposal of assets during the year.
Asset:
Purchase date:
Purchase cost:
Disposal date:
Disposal value:
9. Income
Did you (or your spouse if filing jointly) have any income from wages / salaries /commissions / bonuses?
Please select which of the following COVID-19 stimulus payments (2020 and 2021) you received.
Did you (or your spouse if filing jointly) have any interest income during the year, from;
Did you (or your spouse if filing jointly) have any dividend income during the year?
Did you receive distributions from a company as a director or a shareholder during the year?
Did you (or your spouse if filing jointly) have any self-employment income during the year?
Did you (or your spouse if filing jointly) have any self-employment income during the year?
Do you (or your spouse if filing jointly) hold any form of virtual currency?
Did you receive royalty income?
Do you (or your spouse if filing jointly) hold any form of non-US investment portfolio? If yes; please provide details
Have you made, or do you intend to make a contribution this year
to a Roth IRA/401K?
Were you granted stock or options from your current or previous employer?
If yes, did you dispose of any of your holdings within the tax year?
10. US State Income
Please list any income earned in the USA.
State:
Income Type:
Date Received:
Value (estimate):
11. Rental Income
Did you (or your spouse if filing jointly) have any rental property income during the year?
Do you employ the services of a rental property management agency?
Address/Location
Purchase Date:
Disposal Date:
Residential / Commercial Ownership Details:
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12. Foreign Companies and Partnerships
If you (or your spouse if filing jointly) hold a shareholding or interest in a non-US company or partnership that was greater than 5% of the share capital of the company (including trustee companies), please provide the details below:
Company Name:
Shareholder:
%:
Is this entity dormant?
13. Additional Notes