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

Download a blank fillable Form Td F 90-22.1 - Report Of Foreign Bank And Financial Accounts in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Td F 90-22.1 - Report Of Foreign Bank And Financial Accounts with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

TD F 90-22.1

REPORT OF FOREIGN BANK

OMB No. 1545-2038

1 This Report is for Calendar

AND FINANCIAL ACCOUNTS

(Rev. January 2012)

Year Ended 12/31

Department of the Treasury

Do not use previous editions of

Do NOT file with your Federal Tax Return

Amended

this form

Filer Information

Part I

Type of Filer

Individual

Partnership

Corporation

Consolidated

Fiduciary or Other—Enter type

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

Last Name or Organization Name

7 First Name

8 Middle Initial

Address (Number, Street, and Apt. or Suite No.)

City

11 State

12 Zip/Postal Code

13 Country

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)

Part II

Information on Financial Account(s) Owned Separately

Maximum value of account during calendar year reported

16 Type of account a

Bank

Securities

Other—Enter type below

Name of Financial Institution in which account is held

Account number or other designation

19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held

21 State, if known

22 Zip/Postal Code, if known

23 Country

City

Signature

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 1010.350 (formerly 31 CFR 103.24). 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 USC 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 1010.350 (formerly 31 CFR 103.24).

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

1010.350 (formerly 31 CFR 103.24) . The Social Security number will be used as a means to identify the individual who files the report.

The estimated average burden associated with this collection of information is 75 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.

TD F 90-22.1

Form

(Rev. 1-2012)

Cat. No. 12996D