PART IV. PERIODIC — Internal Revenue Bulletin 2017-6

FACTUAL INFORMATION

This Part IV must be completed by all WTs that have not received a waiver. For purposes of this Part III, “beneficiary or owner” means, unless otherwise specified, any direct or indirect beneficiary or owner for which WT acts as a withholding foreign trust. For Sections B through G of this Part III, while the curing of inadequate documen- tation is permissible, unless otherwise in- dicated, the information reported shall be based on the review and not results ob- tained after curing.

A. General Information

Did WT use an external reviewer to conduct any portion of its periodic review? Y/N

a. If yes, provide the name(s) of

reviewer(s) and the name and address of the firm at which the reviewer is employed. 2. Did WT use an internal reviewer to conduct any portion of its periodic review? Y/N

a. If yes, provide a brief descrip tion of the internal reviewer, such as their department and other roles and responsibilities with respect to the WT’s WT activities. 3. Calendar year reviewed for periodic review.

Caution: On the due date for reporting the factual information relating to the peri- odic review (provided in section 8.04 of the WT Agreement), there must be 15 or more months available on the statutory period for assessment for taxes reportable on Form 1042 of the calendar year for which the review was conducted or the WT must submit, upon request by the IRS, a Form 872, “Consent to Extend the Time to Assess Tax,” that will satisfy the 15- month requirement. The Form 872 must be submitted to the IRS at the address provided in section 11.06 of the WT Agreement.

B. General Information on Beneficiaries or Owners and Review of Beneficiaries or Owners

Total beneficiaries or owners reviewed for periodic review. Note: WT must review all beneficiaries or owners that received a distribution of, or included in their distributive share, a re- portable amount that is attributable to an amount paid to WT in the year under review.

C. Documentation

Total beneficiaries or owners reviewed that are direct beneficiaries or owners.
Total beneficiaries or owners reviewed that are indirect beneficiaries or owners.
Total beneficiaries or owners reviewed with valid documentation.
Total beneficiaries or owners reviewed with invalid documentation or no documentation.
Total beneficiaries or owners reviewed with invalid documentation or no documentation for which valid documentation or additional valid documentation was obtained after the review.
Total direct beneficiaries or owners reviewed for which WT had no documentation at any time that withholding or reporting was required under section 3.02 of the WT Agreement.
Total direct beneficiaries or owners in question 6 for which valid documentation (that relates to the time withholding or reporting was re

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quired) was obtained by WT for each such undocumented direct beneficiary or owner before March 15 of the year following the year in which the WT Agreement was automatically terminated under section 10.03(A) of the WT Agreement. 8. Total beneficiaries or owners reviewed for which treaty benefits were claimed. 9. Total beneficiaries or owners reviewed for which treaty benefits were claimed where WT did not obtain sufficient documentation to establish the payee’s entitlement to treaty benefits (including, where applicable, the treaty statement and limitation on benefits information required by section 4.03(B) of the WT Agreement). 10. Total beneficiaries or owners reviewed that are U.S. accounts (or U.S. reportable accounts under an applicable Model 1 IGA) for chapter 4 purposes. 11. Total beneficiaries or owners reviewed that are U.S. accounts for chapter 4 purposes (or U.S. reportable accounts under an applicable Model 1 IGA) for which WT has obtained valid documentation. 12. If WT is an NFFE, total beneficiaries or owners reviewed that are passive NFFEs with substantial U.S. owners.

D. Withholding

The aggregate amount reported as withheld under chapter 3 by WT on Forms 1042–S.
Number of beneficiaries or owners for which amounts were withheld under chapter 3 (excluding beneficiaries or owners reported in question 10(a) or 11(a) below).
The aggregate amount reported as withheld under chapter 4 by WT on Forms 1042–S.
Number of beneficiaries or owners for which amounts were withheld under chapter 4 (excluding beneficiaries or owners reported in question 10(a) or 11(a) below).
The aggregate amount reported as withheld by WT on Form 1042 under chapter 3 or 4.
Additional withholding required under chapter 4 based on the results of the periodic review (excluding withholding reported in question 10(d) or 11(d) below).
Additional withholding required under chapter 3 based on the results of the periodic review (excluding withholding reported in question 10(d) or 11(d) below).
The aggregate amount of deposits made by WT in accordance with section 3.05 of the WT Agreement.
The aggregate amount withheld by WT but not timely deposited.
Number of partnerships or trusts to which the joint account option of section 9.01 of the WT Agreement was applied (if applicable).

a. Total partners, beneficiaries, or

owners of a partnership or trust to which the joint account option applied for which appropriate documentation was obtained and the appropriate rate of withholding was applied. b. Total partners, beneficiaries,

or owners of a partnership or trust to which the joint account option applied for which appropriate documentation was obtained and the appropriate rate of withholding was not applied. c. Total partners, beneficiaries, or

owners of a partnership or trust to which the joint account option applied for which appropriate documentation was not obtained and the appropriate rate of withholding was not applied. d. Aggregate amount of under withholding resulting from the appropriate rate of withholding not being applied with respect to a partner, beneficiary, or owner of a partnership or trust to which the joint account option applied. 11. Number of partnerships or trusts to which the agency option of section 9.02 of the WT Agreement was applied (if WT includes the partnership or trust in WT’s periodic review).

a. Total partners, beneficiaries, or

owners of a partnership or trust to which the agency option applied for which appropriate documentation was obtained and the appropriate rate of withholding was applied. b. Total partners, beneficiaries,

or owners of a partnership or trust to which the agency option applied for which appropriate documentation was obtained and the appropriate rate of withholding was not applied. c. Total partners, beneficiaries, or

owners of a partnership or trust to which the agency option applied for which appropriate documentation was not obtained and the appropriate rate of withholding was not applied. d. Aggregate amount of under withholding resulting from the appropriate rate of withholding not being applied with respect to a partner, beneficiary, or owner of a partnership or trust to which the agency option applied.

E. Reconciliation of Amounts Reported on Forms 1042–S

The aggregate amount reported paid to WT during the year under review on all Forms 1042–S issued to WT (acting as a withholding foreign trust).
The aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, beneficiaries or owners that are included in WT’s chapter 4 reporting pools (other than the U.S. payee pool) (including a chapter 4 reporting pool of a partnership or trust to which WT applies the agency option) to the extent such amount is attributable to an amount paid to WT in the year under review.
The aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, WT’s chapter 4 reporting pool- U.S. payee pool to the

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extent such amount is attributable to an amount paid to WT in the year under review. 4. If WT made a pooled reporting election under section 6.02(D) of the WT Agreement, the aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, WT’s chapter 3 reporting pools (including chapter 3 reporting pools of a partnership or trust to which WT applies the joint account or agency option) to the extent such amount is attributable to an amount paid to WT in the year under review. 5. If WT did not make a pooled reporting election, the aggregate amount of reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, each direct beneficiary or owner (other than a passthrough beneficiary or owner) (not included in question 2 or 3 above) to the extent such amount is attributable to an amount paid to WT in the year under review (excluding an amount reported in question 6 below). 6. The aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, other WTs, WTs, and QIs as a class to the extent such amount is attributable to an amount paid to WT in the year under review. 7. The aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, participating FFIs, registered deemed-compliant FFIs, and registered deemed-compliant Model 1 IGA FFIs that are passthrough beneficiaries or owners to which WT applies section 9.03 of the WT Agreement as a class with respect to their chapter 4 reporting pools to the extent such amount is attributable to an amount paid to WT in the year under review (excluding amounts included in question 6 above). 8. The aggregate amount reported by WT on Forms 1042–S as distributed to, or included in the distributive share of, indirect beneficiaries

or owners (not included in any of the questions above) to which WT applies section 9.03 of the WT Agreement to the extent such amount is attributable to an amount paid to WT in the year under review. 9. The aggregate amount subject to chapter 3 withholding that WT distributed to, or included in the distributive share of, U.S. beneficiaries or owners not included in a chapter 4 withholding rate pool to the extent such amount is attributable to an amount paid to WT in the year under review. 10. The aggregate amount distributed to, or included in the distributive share of, direct beneficiaries or owners of WT (including partners, beneficiaries, or owners of a partnership or trust to which WT applies the joint account or agency option) that requested individual Form(s) 1042–S and direct beneficiaries or owners that were issued Forms 1042–S under section 6.02(B)(8) of the WT Agreement (excluding an amount reported in question 4 above). 11. Total of questions 2 through 10. 12. The amount of any unreconciled variances (if question 1 minus question 11 is other than 0). 13. The aggregate amount reported by WT on Form 1042 as distributed to, or included in the distributive share of, beneficiaries or owners of WT to the extent such amount is attributable to an amount paid to WT in the year under review. 14. The amount of any unreconciled variances of amounts reported by WT on Forms 1042 and 1042–S (question 13 minus the total of questions 2 through 8). 15. The aggregate amount of any collective claims for refund or credit made by WT.

F. Reporting of Reportable Amounts Other Than Amounts Subject to Chapter 3 Withholding

The aggregate amount of reportable amounts other than amounts subject to chapter 3 withholding received by WT.
The aggregate amount of reportable amounts other than amounts subject to chapter 3 withholding distributed to, or included in the distributive share of, a direct beneficiary or owner that is a U.S. person.
Number of direct beneficiaries or owners that are U.S. persons that are not reported on Form 3520–A or as otherwise required under the WT Agreement (if none enter 0).

G. Reporting on Form 3520–A

The number of Foreign Grantor Trust Owner Statements filed with WT’s Form 3520–A.
The number of Foreign Grantor Trust Beneficiary Statements filed with WT’s Form 3520–A.