Form 14454 - Attachment To Offshore Voluntary Disclosure Letter Page 5
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Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
15h. Was a business person (advisor), accountant, attorney, or return preparer in the U.S. involved in setting up the entity or in advising its use?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” identify the individual(s)
15i. Was a U.S. bank, brokerage firm or other financial services company involved in setting up the entity or in advising its use?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” identify the bank, firm, or company
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. If you choose to apply, however, you are required to provide all the information requested on the foreign account or asset statement.
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 penalties.
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.
14454
Form
(Rev. 7-2014)
Catalog Number 61606G
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