Form 14454 - Attachment To Offshore Voluntary Disclosure Letter Page 4
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Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
12d. Provide the following information about the Financial Institution:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
13a. Did you move any funds to a country outside the jurisdiction of the country where the account was held?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Entity name
Telephone number
Address
13b. If funds were transferred to other financial institutions, provide the following information:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
14a. Are there other individuals affiliated with the account(s)?
Taxpayer
Yes
No
Spouse
Yes
No
14b. If “Yes,” identify each person affiliated with each account, including the nature of their relationship to the account
(e.g., owner, beneficial owner, power of
attorney, signatory authority, etc.)
15a. Is an entity affiliated with the account(s)?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” respond to the following for each entity:
15b. Identify the entity, including the nature of its relationship to the account
(e.g., nominee owner, beneficial owner, power of attorney, parent entity of corporate
account holder, etc.)
15c. Identify the entity’s formal structure
)
(e.g., corporation, foundation, trust, etc.
15d. Identify the country where the entity was organized
15e. Identify the individual(s) and/or organization(s)
who suggested forming the entity and who formed the
(e.g., the foreign bank, an outside professional, etc.)
entity
15f. Identify the individual(s) or organization(s) that managed the entity
15g. Is the entity still in existence?
Taxpayer
Yes
No
Spouse
Yes
No
14454
Form
(Rev. 7-2014)
Catalog Number 61606G
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