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

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Department of the Treasury
REPORT OF FOREIGN BANK
1
TD F 90-22.1
AND FINANCIAL ACCOUNTS
SUPERSEDES ALL PREVIOUS
NOT
OMB No. 1505-0063
Do
file with your Federal Tax Return
EDITIONS
3
Taxpayer Identification Number
2 Type of Filer
1
Filing for Calendar Year
Y
Y
Y
Y
a
Fiduciary
Individual b
Partnership c
Corporation d
Part I
Filer Information
5 First Name
6 Middle Initial
4 Last Name or Organization Name
8 Date of Birth
7 Address (Number, Street, and Apt. or Suite No.)
M
M
D
D
Y
Y
Y
Y
10 State 11 Zip/Postal Code
13
12 Country
Title (Not necessary if reporting a personal
9 City
account)
14 Are these account jointly owned?
15 Number of joint owners
16 Taxpayer Identification Number of joint owner (if known)
Yes b
a
No
17 Last Name or Organization Name
18 First Name
19 Middle Initial
Part II
Information on Financial Accounts
20 Number of Foreign Financial Accounts
21 Type of account
in which a financial interest is held
Securities c
Other _________________________
a
Bank b
23 Account Number or other designation
22 Maximum value of account
a
Under $10,000
c
$100,000 to $1,000,000
Over $1,000,000
b
$10,000 to $99,999
d
25 Country in which account is held
24 Name of Financial Institution with which account is held
26 Does the filer have a financial interest in this account?
27 Last Name or Organization Name of Account Owner
a
Yes
If no, complete boxes 27-35.
b
No
30 Taxpayer Identification Number
28 First Name
29 Middle Initial
31 Address (Number, Street, and Apt. or Suite No.)
32 City
34 Zip/Postal Code
33 State
35 Country
37 Date
36 Signature
M
M
D
D
Y
Y
Y
Y
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 DEFINITION. File this form with:
U.S. Department of the Treasury, P.O. Box 32621, Detroit, MI 48232-0621
.
PRIVACY ACT NOTIFICATION
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 90-22.1in accordance with
5 USC 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.
Disclosure of this information is mandatory. Civil and criminal penalties, including 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.

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