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):
If you (or your spouse if filing jointly) have a beneficial interest in a trust, (settler, trustee or beneficiary), please list these below
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?
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?
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:
If you or your spouse have a self-managed super fund (SMSF), please state the year the fund was formed:
If you or your spouse have a self-managed super fund (SMSF), please state the year the fund was formed:
I'd like to add another superannuation fund
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?
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:
I'd like to add another superannuation fund
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?
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:
7. Pension/Superannuation
(applicable to New Zealand residents)
Do you have a KiwiSaver or Superannuation Account?
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?
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:
Estimated value as at 31st December last year:
I'd like to add another superannuation fund
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?
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:
Estimated value as at 31st December last year:
I'd like to add another superannuation fund
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?
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:
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.
I'd like to add an asset
Asset:
Purchase date:
Purchase cost:
Disposal date:
Disposal value:
9. Income
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 interest income during the year, from;
10. US State Income
Please list any income earned in the USA.
I'd like to add a US income source
State:
Income Type:
Date Received:
Value (estimate):
11. Rental Income
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:
I'd like to add a foreign company/partnership
Company Name:
Shareholder:
%:
13. Additional Notes