Part 1 - Financial Institution Registration

Mailing Address:
Branches
FATCA responsible officer (RO)
POCs

Part 2 - Expanded Affiliated Group

EAGs

Part 3 - Renewal of Agreement for QIs, WPs, or WTs

Responsible Party
PAIs
Filer Name: PCode (optional):
TIN: TIN Type:
More TINs
Address
City State
Zip Country
Phone Fax

ICR-CA Fields

Part I: Withholding Agent
Part II: Recipient
Part III: Type of Income Subject to Withholding
Part 4: Tax Withheld
Part 1 - Financial Institution Registration
1.
5. Mailing Address
6.
8.
10. Responsible Officer (RO)
12. Part 2 - Expanded Affiliated Group
Part 3 - Renewal of Agreement for QIs, WPs, or WTs
13.
14. Responsible Officer
Part 4 - Signature
Part I: Withholding Agent
Part II: Recipient
Part III: Type of Income Subject to Withholding
Part 4: Tax Withheld