Page 2
Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
7c. Did a representative of the foreign financial institution or advisor suggest to you the use of practices, such as holding mail at the institution, using
prepaid phone cards, using credit or debit cards, communicating via fax or email, bank storage of account documentation, or conducting face-to-
face-meetings, to avoid the disclosure of your ownership of the account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7d. Did a representative of the foreign financial institution, one of its U.S. subsidiaries, or advisor provide services in the U.S. related to offshore
accounts (e.g., facilitating opening accounts, reviewing account activity, forwarding account statements, providing investment and/or tax advice,
etc.)?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7e. Did a representative of the foreign financial institution or advisor suggest you meet in a jurisdiction outside the U.S. and other than where the
institution is located?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” provide the dates and locations for all meetings
7f. Did a representative of the foreign financial institution or advisor suggest you either not file a voluntary disclosure with the IRS or repatriate the
foreign funds into the U.S.?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7g. Did an advisor or other person attempt to influence you to move funds from one foreign financial institution to another or from one foreign country
to another?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
8a. What documentation was received by or shown to you regarding opening and maintenance of the account
(e.g., account statements, account opening
?
documents, etc.)
8b. Who showed you the documentation and when?
8c. Did you retain any of the documents?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” identify the documents retained
If “No,” explain why you did not retain them
9. Were you able to make deposits to or withdrawals from your account through the use of a U.S. domestic branch office of the foreign financial
institution?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
14454
Form
(Rev. 12-2017)
Catalog Number 61606G