Fillable Form 14454 - Attachment To Offshore Voluntary Disclosure Letter (Page 3 of 5) in pdf

Form 14454 - Attachment To Offshore Voluntary Disclosure Letter Page 3

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Page 3

Taxpayer Name

Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name

1b. Account Number

10a. Did you or someone on your behalf make deposits

to the account?

(beyond the initial opening deposit)

Taxpayer

Yes

Spouse

Yes

Related entities

Yes

Entity name

Telephone number

Address

If “Yes,” respond to the following:

10b. How did you make a deposit

(e.g., in person, online, phone, ATM, use of third-party, etc.)

10c. What form were the deposits in

(e.g., cash, check, wire, traveler’s check, etc.)

10d. What documents did you receive when a deposit was made

(e.g., receipt, credit memo, etc.)

10e. If funds were transferred from other financial institutions, provide the following information

(if more space is needed, attach additional pages)

Financial Institution(s)/Location(s)

Name on account(s)

Amount of transfer(s)

Date(s) of transfer

11a. Did you or someone on your behalf withdraw money from the account?

Taxpayer

Yes

Spouse

Yes

Related entities

Yes

Entity name

Telephone number

Address

If “Yes,” respond to the following:

11b. How were the funds withdrawn

(e.g., in person, online, phone, ATM, use of third-party, etc.)

11c. What form were the withdrawals in

(e.g., cash, check, wire, debit, etc.)

11d. What documents were received when a withdrawal was made

(e.g., receipt, debit memo, etc.)

11e. If funds were transferred to other offshore financial institutions, provide the following information

(if more space is needed, attach additional pages)

Financial Institution(s)/Location(s)

Name on account(s)

Amount of transfer(s)

Date(s) of transfer

12a. Did you move any funds into the United States during the life of the account?

Taxpayer

Yes

Spouse

Yes

Related entities

Yes

Entity name

Telephone number

Address

If “Yes,” respond to the following:

12b. In what form did you move the funds

(e.g., cash, check, wire, bank checks, etc.)

12c. Did you engage in any transactions or series of transactions or use any third parties or other methods or schemes to move the money back into the

United States

? If yes, explain and identify all individuals and entities involved

(e.g. loans, business invoices, other entities, third parties, etc.)

14454

Form

(Rev. 12-2017)

Catalog Number 61606G