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

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REPORT OF FOREIGN BANK
OMB No. 1545-2038
TD F 90-22.1
1 This Report is for Calendar
AND FINANCIAL ACCOUNTS
Year Ended 12/31
(Rev October 2008)
Department of the Treasury
Do not use previous editions of
Do NOT file with your Federal Tax Return
this form after
Amended
December 31, 2008
Part I
Filer Information
2
Type of Filer
'
a
Individual
b
Partnership
c
Corporation
d
Consolidated
e
Fiduciary or Other
Enter type
3
U.S. Taxpayer Identification Number
4 Foreign identification (Complete only if item 3 is not applicable)
5
Individual's Date of Birth
MM/DD/YYYY
a Type:
Passport
Other
If filer has no U.S. Identification
Number complete Item 4.
b Number
c Country of Issue
6
Last Name or Organization Name
7
First Name
8
Middle Initial
9
Address (Number, Street, and Apartment or Suite Number)
10
City
11
State
12 ZIP/Postal Code
13 Country
14
Does the filer have a financial interest in 25 or more financial accounts?
Yes
If 'Yes' enter total number of accounts
(If 'Yes' is checked, do not complete Part II or Part III, but retain records of this information)
No
Part II Information on Financial Account(s) Owned Separately
'
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 in wh ich 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
Signature
44
Filer Signature
45
Filer Title, if not reporting a personal account
46
Date (MM/DD/YYYY)
File this form with: U.S. Department of the Treasury, P.O. Box 32621, Detroit, MI 48232-0621
This form should be used to report a financial interest in, signature authority, or other authority over one or more financial accounts in foreign
countries, as required by the Department of the Treasury Regulations (31 CFR 103). No report is required if the aggregate value of the accounts
did not exceed $10,000. See Instructions For Definitions.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on TD F
90-22.1 in accordance with 5 UC 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 103.
The principal purpose for collecting the information is to assure maintenance of reports where such reports or records have a high degree of
usefulness in criminal, tax, or regulatory investigations or proceedings. The information collected may be provided to those officers and
employees of any constituent unit of the Department of the Treasury who have a need for the records in the performance of their duties. The
records may be referred to any other department or agency of the United States upon the request of the head of such department or agency
for use in a criminal, tax, or regulatory investigation or proceeding. The information collected may also be provided to appropriate state, local
and foreign law enforcement and regulatory personnel in the performance of their official duties. Disclosure of this information is mandatory.
Civil and criminal penalties, including in certain circumstances a fine of not more than $500,000 and imprisonment of not more than five years,
are provided for failure to file a report, supply information, and for filing a false or fraudulent report. Disclosure of the Social Security number
is mandatory. The authority to collect is 31 CFR 103. The Social Security number will be used as a means to identify the individual who files
the report.
The estimated average burden associated with th is collection of information is 20 minutes per respondent or record keeper, depending on
individual circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing the burden should be
directed to the Internal Revenue Service, Bank Secrecy Act Policy, 5000 Ellin Road C-3-242, Lanham MD 20706.
APPRV #053
Form TD F 90-22.1 (Rev 10-2008)
FDIZ9101L 10/02/08

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