Part 4 of Application — 1022 Publ 5262 (PDF)

All applicant types will complete each question in Part 4.

Part 4 Question	Instructions
Has the applicant or any related entity previously applied for QI/WP/WT status?	Select the appr	opriate respo	nse.
Is the Applicant compliant to date with its FATCA requirements	Select the appropriate response. For purposes of this question, an applicant is compliant with its FATCA requirements if it has obtained and maintained its status as a participating FFI, registered deemed-compliant FFI, registered deemed-compliant Model 1 IGA FFI or direct reporting NFFE. An FFI that agrees to be treated as a participating FFI or registered deemed-compliant FFI (e.g., a foreign central bank of issue or a foreign branch of a U.S. fnancial institution) may select “yes” if it qualifes for such status. If the applicant is not subject to any FATCA requirements (for example, a NFFE other than a direct reporting NFFE, or an FFI that is a retirement fund), select “yes.”	Select the appropriate response. For purposes of this question, an applicant is compliant with its FATCA requirements if it has obtained and maintained its status as a participating FFI, registered deemed-compliant FFI, registered deemed-compliant Model 1 IGA FFI or direct reporting NFFE. An FFI that agrees to be treated as a participating FFI or registered deemed-compliant FFI (e.g., a foreign central bank of issue or a foreign branch of a U.S. fnancial institution) may select “yes” if it qualifes for such status. If the applicant is not subject to any FATCA requirements (for example, a NFFE other than a direct reporting NFFE, or an FFI that is a retirement fund), select “yes.”	Select the appropriate response. For purposes of this question, an applicant is compliant with its FATCA requirements if it has obtained and maintained its status as a participating FFI, registered deemed-compliant FFI, registered deemed-compliant Model 1 IGA FFI or direct reporting NFFE. An FFI that agrees to be treated as a participating FFI or registered deemed-compliant FFI (e.g., a foreign central bank of issue or a foreign branch of a U.S. fnancial institution) may select “yes” if it qualifes for such status. If the applicant is not subject to any FATCA requirements (for example, a NFFE other than a direct reporting NFFE, or an FFI that is a retirement fund), select “yes.”
Is the applicant compliant to date with the anti- money laundering (AML)/Know Your Customer (KYC) requirements in its local jurisdiction?	Select the appropriate response. For purposes of this question, an applicant is compliant with the anti-money laundering (AML)/know-your-customer (KYC) requirements in its jurisdiction if the regulator or other governmental authority or agency with oversight over the applicant’s compliance with such AML/KYC procedures has not imposed a criminal or civil penalty or sanction on the applicant (or any branch or offce thereof) due to the applicant’s failure to properly identify account holders, partners, owners, or benefciaries under the requirements of those procedures.	Select the appropriate response. For purposes of this question, an applicant is compliant with the anti-money laundering (AML)/know-your-customer (KYC) requirements in its jurisdiction if the regulator or other governmental authority or agency with oversight over the applicant’s compliance with such AML/KYC procedures has not imposed a criminal or civil penalty or sanction on the applicant (or any branch or offce thereof) due to the applicant’s failure to properly identify account holders, partners, owners, or benefciaries under the requirements of those procedures.	Select the appropriate response. For purposes of this question, an applicant is compliant with the anti-money laundering (AML)/know-your-customer (KYC) requirements in its jurisdiction if the regulator or other governmental authority or agency with oversight over the applicant’s compliance with such AML/KYC procedures has not imposed a criminal or civil penalty or sanction on the applicant (or any branch or offce thereof) due to the applicant’s failure to properly identify account holders, partners, owners, or benefciaries under the requirements of those procedures.
Has the applicant or any related entity been in default of its QI agreement (or a prior QI agreement, or a prior QI agreement of a terminated QI) based on the events of default listed in section 11.04 of Rev. Proc. 2014-39 (or an updated version of the QI agreement provided in a subsequent revenue procedure) or its WP agreement or WT agreement (or a prior WP or WT agreement, or a prior WP or WT agreement of a terminated WP or WT) based on the events of default listed in section 10.05 of Rev. Proc. 2014-47 (or an updated version of the WP and WT agreement provided in a subsequent revenue procedure)?	Select “Yes” if the applicant or a related entity has received a notice of default of its QI, WP, or WT agreement from the IRS. Otherwise, select “No.” If yes, provide a description of the events of default of the QI, WP, or WT agreement and how they have been resolved. Files can be uploaded in Part 4, if additional space is needed.	Select “Yes” if the applicant or a related entity has received a notice of default of its QI, WP, or WT agreement from the IRS. Otherwise, select “No.” If yes, provide a description of the events of default of the QI, WP, or WT agreement and how they have been resolved. Files can be uploaded in Part 4, if additional space is needed.	Select “Yes” if the applicant or a related entity has received a notice of default of its QI, WP, or WT agreement from the IRS. Otherwise, select “No.” If yes, provide a description of the events of default of the QI, WP, or WT agreement and how they have been resolved. Files can be uploaded in Part 4, if additional space is needed.