Form Td F 90-22.1 - Report Of Foreign Bank And Financial Accounts Page 2
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1
2Form TD F 90-22.1
Continuation Page
This side can be copied as many times as necessary in order to provide information on all accounts.
3
Taxpayer Identification Number
Page Number
1
Filing for Calendar Year
4 Filer Last Name or Business Name
Y
Y
Y
Y
OF
2 Type of Filer
21 Type of Account
22 Maximum Value of Account
a
Individual
c
Corporation
a
Bank
Under $10,000
c
$100,000 to $1,000,000
c
Other
a
b
Partnership
d
Fiduciary
b
Securities
b
Over $1,000,000
$10,000 to $99,999
d
24 Name of Financial Institution with which account is held
23 Account Number or other designation
25 Country in which account is held
26 Does the filer have a financial interest
27 Last Name or Organization Name of Account Owner
in this account?
a
Yes
b
No
If no, complete boxes 27-35.
28 First Name
31 Address (Number, Street, and Apt. or Suite No.)
30
29 Middle Initial
Taxpayer Identification Number
32 City
33 State
34 Zip/Postal Code
35 Country
2 Type of Filer
21 Type of Account
22 Maximum Value of Account
a
Individual
c
Corporation
a
Bank
Under $10,000
c
$100,000 to $1,000,000
c
Other
a
b
Partnership
d
Fiduciary
b
Securities
b
Over $1,000,000
$10,000 to $99,999
d
24 Name of Financial Institution with which account is held
23 Account Number or other designation
25 Country in which account is held
26 Does the filer have a financial interest
27 Last Name or Organization Name of Account Owner
in this account?
a
Yes
b
No
If no, complete boxes 27-35.
28 First Name
31 Address (Number, Street, and Apt. or Suite No.)
30
29 Middle Initial
Taxpayer Identification Number
32 City
33 State
34 Zip/Postal Code
35 Country
2 Type of Filer
21 Type of Account
22 Maximum Value of Account
a
Individual
c
Corporation
a
Bank
Under $10,000
c
$100,000 to $1,000,000
c
Other
a
b
Partnership
d
Fiduciary
b
Securities
b
Over $1,000,000
$10,000 to $99,999
d
24 Name of Financial Institution with which account is held
23 Account Number or other designation
25 Country in which account is held
26 Does the filer have a financial interest
27 Last Name or Organization Name of Account Owner
in this account?
a
Yes
b
No
If no, complete boxes 27-35.
28 First Name
31 Address (Number, Street, and Apt. or Suite No.)
30
29 Middle Initial
Taxpayer Identification Number
32 City
33 State
34 Zip/Postal Code
35 Country
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
.
Paperwork Reduction Act. The estimated average burden associated with this collection of information is 10 minutes per respondent or
recordkeeper, depending on individual circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing
the burden should be directed to the Department of the Treasury, Financial Crimes Enforcement Network, Suite 200, 2070 Chain Bridge Road,
Vienna VA 22182-2536.
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