Form Td F 90-22.1 - Report Of Foreign Bank And Financial Accounts Page 4

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Part IV
Information on Financial Account(s) Where Filer has Signature or Other
Form TD F 90-22.1
Authority but No Financial Interest in the Account(s)
Page Number
Complete a Separate Block for Each Account
of
This side can be copied as many times as necessary in order to provide information on all accounts.
1
Filing for calendar year
3-4
Check appropriate Identification Number
6
Last Name or Organization Name
Taxpayer Identification Number
Foreign Identificaiton Number
Enter identification number here:
'
15
Maximum value of account during calendar year reported
16
Type of account
a
Bank
b
Securities
c
Other
Enter type below
17
Name of Financial Institution with which account is held
18
Account number or other designation
19
Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City
21
State, if known
22
Zip/Postal Code, if known
23
Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial
38
Address (Number, Street, and Apartment or Suite No.)
39
City
40
State
41
Zip/Postal Code
42
Country
43
Filer's Title with this Owner
'
15
Maximum value of account during calendar year reported
16
Type of account
a
Bank
b
Securities
c
Other
Enter type below
17
Name of Financial Institution with which account is held
18
Account number or other designation
19
Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City
21
State, if known
22
Zip/Postal Code, if known
23
Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial
38
Address (Number, Street, and Apartment or Suite No.)
39
City
40
State
41
Zip/Postal Code
42
Country
43
Filer's Title with this Owner
'
15
Maximum value of account during calendar year reported
16
Type of account
a
Bank
b
Securities
c
Other
Enter type below
17
Name of Financial Institution with which account is held
18
Account number or other designation
19
Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City
21
State, if known
22
Zip/Postal Code, if known
23
Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial
38
Address (Number, Street, and Apartment or Suite No.)
39
City
40
State
41
Zip/Postal Code
42
Country
43
Filer's Title with this Owner
APPRV #053
Form TD F 90-22.1 (Rev 10-2008)
FDIZ9104L 10/02/08

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