Form 14457 - Offshore Voluntary Disclosure Letter Page 3

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11. Please check the box to estimate the range of potential total unreported income from the offshore account(s) during each disclosure
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Estimated Total
Unreported Income
$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
Greater than $10,000,000
a. Please list all of your accounts for which there is unreported income
(attach additional sheets, if necessary)
For each foreign financial account of which you have control or are a beneficial owner, complete the attached Form 14454, Attachment
to Offshore Voluntary Disclosure Letter. Please ensure all pages of the attachment include your name, the last four digits of your
taxpayer identification number, the name of the foreign financial institution, and the account number for which you are responding.
To be included with all Forms 14457:
By signing this document, I certify that I am willing to continue to cooperate with the Internal Revenue Service, including in assessing
my income tax liabilities and making good faith arrangements to pay all taxes, interest, and penalties associated with this voluntary
Under penalties of perjury, I declare that I have examined this document, all attachments, and accompanying statements, and to the
best of my knowledge and belief, they are true, correct, and complete.
Signature of Taxpayer
Print Name
Signature of Taxpayer's Spouse
Print Name
Signature must be original (must be mailed), preferably in blue ink. Photocopied, facsimile, or electronic signatures are not
acceptable. The power of attorney may not sign the voluntary disclosure letter on behalf of the taxpayers.
IRS reserves the right to make further contacts with the taxpayer to clarify his/her submission.
Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this foreign account or asset statement to carry out the Internal Revenue laws of the United States. Our authority to ask for information is
sections 6001, 6109, 7801, 7803 and the regulations thereunder. This information will be used to determine and collect the correct amount of tax under the terms of the
offshore voluntary disclosure program. You are not required to apply for participation in the offshore voluntary disclosure program. However, if you choose to apply you are
required to provide all the information requested on the offshore voluntary disclosure letter.
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document displays a valid OMB control
number. Books or records relating to a document or its instructions must be retained as long as their contents may become material in the administration of any Internal
Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. Section 6103, however, allows or requires the Internal Revenue
Service to disclose or give this information to others as described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to
enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also
disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application. Providing false information may subject you to
The time needed to complete and submit the foreign account or asset statement will vary depending on individual circumstances. The estimated average time is: 2 hour.
If you have comments concerning the accuracy of this time estimate or suggestions for making the foreign account or asset statement simpler, we would be happy to hear
from you. Comments should be sent to the Internal Revenue Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:SP, Washington, DC 20224.
Catalog Number 61637F
(Rev. 11-2017)


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