Form TD F 90-22.1 (Rev. July 2000)

REPORT OF FOREIGN BANK
AND FINANCIAL ACCOUNTS
Department of the Treasury
TD F 90-22.1
(Rev. 7/00) SUPERSEDES ALL
PREVIOUS EDITIONS
1 Filing for Calendar Year
Y Y Y Y
Part I
1
Do NOT file with your Federal Tax Return
2 Type of Filer
a Individual
b
Partnership
c
Corporation
OMB No.1506-0009
d
Fiduciary
3 Taxpayer Identification Number
Filer Information
5 First Name
4 Last Name or Organization Name
6 Middle Initial
8 Date of Birth
M M D D
7 Address (Number, Street, and Apt. or Suite No.)
9 City
10 State
14 Are these accounts jointly owned?
a
Yes
b
No
15 Number of joint owners
11 Zip/Postal Code
17 Last Name or Organization Name
Part II
12 Country
Y
Y
Y
13 Title (Not necessary if reporting
a personal account.)
16 Taxpayer Identification Number of joint owner (if known)
18 First Name
19 Middle Initial
Information on Financial Accounts
20 Number of Foreign Financial Accounts
in which a financial interest is held
22 Maximum value of account
a
Under $10,000
b
$10,000 to $99,999
c
d
21 Type of account
a
Bank
b
$100,000 to $1,000,000
Over $1,000,000
Securities
c
Other
23 Account Number or other designation
24 Name of Financial Institution with which account is held
25 Country in which account is held
26 Does the filer have a financial interest in this account?
a
Yes
b
No
If no, complete boxes 27-35.
27 Last Name or Organization Name of Account Holder
28 First Name
29 Middle Initial
31 Address (Number, Street, and Apt. or Suite No.)
33 State
Y
34 Zip/Postal Code
30 Taxpayer Identification Number
32 City
35 Country
36 Signature
37 Date
M M D
D
Y
Y
Y
Y
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 103). No report is required if the aggregate value of the accounts did
not exceed $10,000. SEE INSTRUCTIONS FOR DEFINITION. File this form with:
U.S. Department of the Treasury, P.O. Box 32621, Detroit, MI 48232-0621.
PRIVACY ACT NOTIFICATION
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 522a(e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 103.
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 103. The Social Security number will be used as a means
to identify the individual who files the report.
Continuation Page
1 Filing for Calendar Year
Y Y Y Y
2 Type of Filer
a
Individual
b
Partnership
c
d
Form TD F 90-22.1
This side can be copied as many times as necessary in order to provide information on all accounts.
3 Taxpayer Identification Number
4 Filer Last Name or Business Name
Page Number
OF
21 Type of Account
a
Bank
c
b
Securities
Corporation
Fiduciary
Other
23 Account Number, or other designation
22 Maximum value of account
a
Under $10,000
c
b
$10,000 to $99,999
d
$100,000 to $1,000,000
Over $1,000,000
24 Name of Financial Institution with which account is held
25 Country in which account is held
27 Last Name or Organization Name of Account Owner
26 Does the filer have a financial
interest in this account? a
Yes
No
If no, complete boxes 27-35. b
28 First Name
29 Middle Initial
30 Taxpayer Identification Number
31 Address (Number, Street, and Apt. or Suite No.)
32 City
33 State
34 Zip/Postal Code
35 Country
2 Type of Filer
a
Individual
b
Partnership
c
d
21 Type of Account
a
Bank
c
b
Securities
Corporation
Fiduciary
Other
23 Account Number, or other designation
22 Maximum value of account
a
Under $10,000
c
b
$10,000 to $99,999
d
$100,000 to $1,000,000
Over $1,000,000
24 Name of Financial Institution with which account is held
27 Last Name or Organization Name of Account Owner
25 Country in which account is held 26 Does the filer have a financial
interest in this account? a
Yes
No
If no, complete boxes 27-35. b
28 First Name
29 Middle Initial
30 Taxpayer Identification Number
31 Address (Number, Street, and Apt. or Suite No.)
32 City
33 State
34 Zip/Postal Code
35 Country
2 Type of Filer
a
Individual
b
Partnership
c
d
21 Type of Account
a
Bank
c
b
Securities
Corporation
Fiduciary
Other
23 Account Number, or other designation
22 Maximum value of account
a
Under $10,000
c
b
$10,000 to $99,999
d
$100,000 to $1,000,000
Over $1,000,000
24 Name of Financial Institution with which account is held
27 Last Name or Organization Name of Account Owner
25 Country in which account is held 26 Does the filer have a financial
interest in this account? a
Yes
No
If no, complete boxes 27-35. b
28 First Name
29 Middle Initial
30 Taxpayer Identification Number
31 Address (Number, Street, and Apt. or Suite No.)
32 City
33 State
34 Zip/Postal Code
35 Country
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 103). No report is required if the aggregate value of the accounts did
not exceed $10,000. SEE INSTRUCTIONS FOR DEFINITION. File this form with:
U.S. Department of the Treasury, P.O. Box 32621, Detroit, MI 48232-0621.
Paperwork Reduction Act. The estimated average burden associated with this collection of information is 10 minutes per respondent or
recordkeeper, depending on individual circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing the
burden should be directed to the Department of the Treasury, Financial Crimes Enforcement Network, Suite 200, 2070 Chain Bridge Road, Vienna,
VA 22182-2536. You are not required to provide the requested information unless a form displays a valid OMB control number.
INSTRUCTIONS
General Instructions
Who Must File this Report Each Unites States person, who has a
financial interest in or signature authority, or other authority over any
financial accounts, including bank, securities, or other types of
financial accounts in a foreign country, if the aggregate value of
these financial accounts exceeds $10,000 at any time during the
calendar year, must report that relationship each calendar year by
filing TD F 90-22.1 with the Department of the Treasury on or before
June 30, of the succeeding year.
Exceptions
An officer or employee of a bank which is subject to the supervision
of the Comptroller of the Currency, the Board of Governors of the
Federal Reserve System, the Office of Thrift Supervision, or the
Federal Deposit Insurance Corporation need not report that he has
signature or other authority over a foreign bank, securities or other
financial account maintained by the bank, if the officer of employee
has NO personal financial interest in the account.
An officer or employee of a domestic corporation whose equity
securities are listed upon national securities exchanges or which has
assets exceeding $10 million and 500 or more shareholders of
record need not file such a report concerning the other signature
authority over a foreign financial account of the corporation, if he has
NO personal financial interest in the account and he has been
advised in writing by the chief financial officer of the corporation that
the corporation has filed a current report, which includes that
account.
Report any financial account (except a military banking facility as
defined in these instructions) that is located in a foreign country,
even if it is held at an affiliate of a United States bank or other
financial institution. Do not report any account maintained with a
branch, agency, of other office of a foreign bank or other institution
that is located in the United States, Guam, Puerto Rico, and the
Virgin Islands.
General Definitions
United States Person The term “United States person” means (1) a
citizen or resident of the United States, (2) a domestic partnership,
(3) a domestic corporation, or (4) a domestic estate or trust.
Financial Account Generally includes any bank, securities,
securities derivatives or other financial instruments accounts. Such
accounts generally also encompass any accounts in which the
assets are held in a commingled fund, and the account owner holds
an equity interest in the fund. The term also means any savings,
demand, checking, deposit, time deposit, or any other account
maintained with a financial institution or other person engaged in the
business of a financial institution.
Account in a Foreign Country A “foreign country” includes all
geographical areas located outside the United States, Guam, Puerto
Rico, and the Virgin Islands.
Financial Interest A financial interest in a bank, securities, or other
financial account in a foreign country means an interest described in
either of the following two paragraphs:
(1) A United States person has a financial interest in each account
for which such person is the owner of record or has legal title,
whether the account is maintained for his or her own benefit or for
the benefit of others including non-United States persons. If an
account is maintained in the name of two persons jointly, or if several
persons each own a partial interest in an account, each of those
United States persons has a financial interest in that account.
(2) A United States person has a financial interest in each bank,
securities, or other financial account in a foreign country for which the
owner of record or holder of legal title is: (a) a person acting as an agent,
nominee, attorney, or in some other capacity on behalf of the U.S. person;
(b) a corporation in which the United States person owns directly or
indirectly more than 50 percent of the total value of shares of stock; (c) a
partnership in which the United States person owns an interest in more
than 50 percent of the profits (distributive share of income); or (d) a trust
in which the United States person either has a present beneficial interest
in more than 50 percent of the assets or from which such person receives
more than 50 percent of the current income.
Signature or Other Authority Over an Account A person has signature
authority over an account if such person can control the disposition of
money or other property in it by delivery of a document containing his or her
signature (or his or her signature and that of one or more other persons) to
the bank or other person with whom the account is maintained.
Other authority exists in a person who can exercise comparable power
over an account by direct communication to the bank or other person with
whom the account is maintained, either orally or by some other means.
Military Banking Facility Do not consider as an account in a foreign
country, an account in an institution known as a “United States military
banking facility” (or “United States military finance facility”) operated by a
United States financial institution designated by the United States
Government to serve U.S. Government installations abroad, even if the
United States military banking facility is located in a foreign country.
Filing Information
When and Where to File - This report must be filed on or before June 30
each calendar year with the Department of the Treasury, Post Office Box
32621, Detroit, MI 48232-0621, or it may be hand carried to any local
office of the Internal Revenue Service for forwarding to the Department of
the Treasury, Detroit, MI.
EXPLANATIONS FOR SPECIFIC ITEMS
Consolidated Reporting
A corporation which owns directly or indirectly more than 50 percent
interest in one or more other entities will be permitted to file a consolidated report on TD F 90-22.1, on behalf of itself and such other entities
provided that a listing of them is made part of the consolidated report.
Such reports should be signed by an authorized official of the parent
corporation.
If the group of entities covered by a consolidated report has a financial
interest in 25 or more foreign financial accounts, the reporting corporation
need only note that fact on the form in Item 20. It will, however, be
required to provide detailed information concerning each account when
so requested by the Secretary or his delegate.
Item 14
If the filer owns the account jointly with any other party, then yes should
be marked.
Item 15
If the filer holds this account with only one (1) other party, and all
accounts listed are held jointly with that party, then complete items 16, 17,
18, and 19. Otherwise leave these items blank.
Item 20
If the filer holds a financial interest in more than 25 foreign financial
accounts, indicate the number in this box and do not complete any further
items in Part II.
Any person who lists more than 25 foreign financial accounts in item 20
must when requested by the Department of the Treasury provide all the
information called for in Part II.
Item 22
Account Valuation
For item 22, the maximum value of an account is the largest amount of
currency and non-monetary assets that appear on any quarterly or more
frequent account statement issued for the applicable year. If periodic
account statements are not so issued, the maximum account asset value
is the largest amount of currency and non-monetary assets in the account
at any time during the year. Convert foreign currency by using the official
exchange rate at the end of the year. In valuing currency of a country that
uses multiple exchange rates, use the rate which would apply if the
currency in the account were converted into United States dollars at the
close of the calendar year.
The value of stock, other securities or other non-monetary assets in an
account reported on TD F 90-22.1 is the fair market value at the end of
the calendar year, or if withdrawn from the account, at the time of the
withdrawal.
For purposes of item 22, if you had a financial interest in more than one
account, each account is to be valued separately in accordance with the
foregoing two paragraphs. If you had a financial interest in one or more
but fewer than 25 accounts, and you are unable to determine whether the
maximum value of these accounts exceeded $10,000 at any time during
the year, complete Part II or III for each of these accounts.
Item 26
United States Persons with Authority Over but No Financial Interest in an
Account - Except as provided in the following paragraph, you must state
the name, address, and identifying number of each owner of an account
over which you had authority, but if you complete items 27-35 for more
than one account of the same owner, you need identify the owner only
once. If you complete items 27-35 for one or more accounts in which no
United States person had a financial interest, you may state on the first
line of this item, in lieu of supplying information about the owner, “No U.S.
person had any financial interest in the foreign account.” This statement
must be based upon the actual belief of the person filing this form after he
or she has taken reasonable measures to ensure its correctness.
If you complete Part II for accounts owned by a domestic corporation and
its domestic and/or foreign subsidiaries, you may treat them as one owner
and write in the space provided, the name of the parent corporation,
followed by “and related entities,” and the identifying number and address
of the parent corporation.
Item 36
Signature
This report must be signed by the person named in Part I. If the report is
being filed on behalf of a partnership, corporation, or fiduciary, it must be
signed by an authorized individual.
Penalties
For criminal penalties for failure to file a report, supply information, and for
filing a false or fraudulent report, see 31 USC 5322(a), 31 USC 5322(b),
and 18 USC 1001.