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FBAR Form
Part IV
Information on Financial Account(s) Where Filer has Signature Authority but No
Financial Interest in the Account(s)
Form TD F 90-22.1
Page Number
of
Complete a Separate Block for Each Account
This side can be copied as many times as necessary in order to provide information on all accounts.
1
Filing for calendar
year
3–4
Check appropriate Identification Number
Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
6
Last Name or Organization Name
15
Maximum value of account during calendar year reported 16 Type of account a Bank b Securities c Other—Enter type below
17
Name of Financial Institution in which account is held
18
Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City 21 State, if known 22 Zip/Postal Code, if known 23 Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial 38 Address (Number, Street, and Apt. or Suite No.)
39
City 40 State 41 Zip/Postal Code 42 Country
43
Filer's Title with this Owner
15
Maximum value of account during calendar year reported 16 Type of account a Bank b Securities c Other—Enter type below
17
Name of Financial Institution in which account is held
18
Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City 21 State, if known 22 Zip/Postal Code, if known 23 Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial 38 Address (Number, Street, and Apt. or Suite No.)
39
City 40 State 41 Zip/Postal Code 42 Country
43
Filer's Title with this Owner
15
Maximum value of account during calendar year reported 16 Type of account a Bank b Securities c Other—Enter type below
17
Name of Financial Institution in which account is held
18
Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20
City 21 State, if known 22 Zip/Postal Code, if known 23 Country
34
Last Name or Organization Name of Account Owner
35
Taxpayer Identification Number of Account Owner
36
First Name
37
Middle initial 38 Address (Number, Street, and Apt. or Suite No.)
39
City 40 State 41 Zip/Postal Code 42 Country
43
Filer's Title with this Owner
Form
TD F 90-22.1 (Rev. 1-2012)
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