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FBAR Form is a report of foreign bank and financial accounts. This report consists of five parts. The five parts are: Filer Information, Information on Financial Account(s) Owned Separately, Information on Financial Account(s) Owned Jointly, Information on Financial Account(s) Where Filer has Signature Authority but No Financial Interest in the Account(s), Information on Financial Account(s) Where the Filer is Filing a Consolidated Report.

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TD F 90-22.1
(Rev. January 2012)
Department of the Treasury
Do not use previous editions of
this form
Do NOT file with your Federal Tax Return
OMB No. 1545-2038
1 This Report is for Calendar
Year Ended 12/31
Part I
Filer Information
2 Type of Filer
Individual b Partnership c Corporation d Consolidated e Fiduciary or Other—Enter type
3 U.S. Taxpayer Identification Number
If filer has no U.S. Identification
Number complete Item 4.
4 Foreign identification (Complete only if item 3 is not applicable.)
a Type:
Passport Other
b Number c Country of Issue
Individual’s Date of Birth
6 Last Name or Organization Name 7 First Name 8 Middle Initial
Address (Number, Street, and Apt. or Suite No.)
City 11 State 12 Zip/Postal Code 13 Country
14 Does the filer have a financial interest in 25 or more financial accounts?
Yes If “Yes” enter total number of accounts
(If “Yes” is checked, do not complete Part II or Part III, but retain records of this information)
Part II
Information on Financial Account(s) Owned Separately
15 Maximum value of account during calendar year reported 16 Type of account a Bank b Securities c Other—Enter type below
Name of Financial Institution in which account is held
Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
City 21 State, if known 22 Zip/Postal Code, if known 23 Country
Filer Signature
45 Filer Title, if not reporting a personal account 46 Date (MM/DD/YYYY)
File this form with: U.S. Department of the Treasury, P.O. Box 32621, Detroit, MI 48232-0621
This form should be used to report a financial interest in, signature authority, or other authority over one or more financial accounts in foreign
countries, as required by the Department of the Treasury Regulations 31 CFR 1010.350 (formerly 31 CFR 103.24). No report is required if the aggregate
value of the accounts did not exceed $10,000. See Instructions For Definitions.
Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on TD F
90-22.1 in accordance with 5 USC 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 1010.350 (formerly 31 CFR 103.24).
The principal purpose for collecting the information is to assure maintenance of reports where such reports or records have a high degree of
usefulness in criminal, tax, or regulatory investigations or proceedings. The information collected may be provided to those officers and employees of
any constituent unit of the Department of the Treasury who have a need for the records in the performance of their duties. The records may be referred
to any other department or agency of the United States upon the request of the head of such department or agency for use in a criminal, tax, or
regulatory investigation or proceeding. The information collected may also be provided to appropriate state, local, and foreign law enforcement and
regulatory personnel in the performance of their official duties. Disclosure of this information is mandatory. Civil and criminal penalties, including in
certain circumstances a fine of not more than $500,000 and imprisonment of not more than five years, are provided for failure to file a report, supply
information, and for filing a false or fraudulent report. Disclosure of the Social Security number is mandatory. The authority to collect is 31 CFR
1010.350 (formerly 31 CFR 103.24) . The Social Security number will be used as a means to identify the individual who files the report.
The estimated average burden associated with this collection of information is 75 minutes per respondent or record keeper, depending on individual
circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing the burden should be directed to the Internal
Revenue Service, Bank Secrecy Act Policy, 5000 Ellin Road C-3-242, Lanham MD 20706.
Cat. No. 12996D
TD F 90-22.1 (Rev. 1-2012)
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