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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 1 of 10
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 406mm (16") 3 279mm (11"), FOLD TO 203mm (8") 3 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Date
TD F 90-22.1
Do not use previous editions of
this form after
December 31, 2008
Part I
Signature
O.K. to print
Revised proofs
requested
OMB No. 1545-2038
1 This Report is for Calendar
Year Ended 12/31
Amended
Do NOT file with your Federal Tax Return
Filer Information
Type of Filer
a
3
Date
REPORT OF FOREIGN BANK
AND FINANCIAL ACCOUNTS
(Rev. October 2008)
Department of the Treasury
2
Action
Individual
b
Partnership
c
U.S. Taxpayer Identification Number
4
Corporation
Consolidated e
Passport
Last Name or Organization Name
9
Address (Number, Street, and Apt. or Suite No.)
5
Individual’s Date of Birth
MM/DD/YYYY
8
Middle Initial
Other
b Number
6
c Country of Issue
7
10
City
11 State
14
Does the filer have a financial interest in 25 or more financial accounts?
Yes
Fiduciary or Other—Enter type
Foreign identification (Complete only if item 3 is not applicable.)
a Type:
If filer has no U.S. Identification
Number complete Item 4.
d
First Name
12 Zip/Postal Code
13 Country
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)
No
Part II
Information on Financial Account(s) Owned Separately
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
23 Country
Signature
44 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 103). No report is required if the aggregate value of the accounts
did not exceed $10,000. See Instructions For Definitions.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 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.
The estimated average burden associated with this collection of information is 20 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
Form
TD F 90-22.1
(Rev. 10-2008)
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 2 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Continued—Information on Financial Account(s) Owned Separately
Part II
Complete a Separate Block for Each Account Owned Separately
Form TD F 90-22.1
Page Number
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
6
of
Last Name or Organization Name
Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
21 State, if known
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
21 State, if known
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
21 State, if known
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
21 State, if known
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
16 Type of account a
23 Country
Bank b
Securities c
Other—Enter type below
22 Zip/Postal Code, if known
16 Type of account a
23 Country
Bank b
Securities c
Other—Enter type below
22 Zip/Postal Code, if known
16 Type of account a
23 Country
Bank b
Securities c
Other—Enter type below
22 Zip/Postal Code, if known
16 Type of account a
23 Country
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
22 Zip/Postal Code, if known
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
15
20 City
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
15
20 City
Securities c
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
15
20 City
Bank b
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
15
20 City
16 Type of account a
22 Zip/Postal Code, if known
16 Type of account a
23 Country
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
23 Country
Form
TD F 90-22.1
(Rev. 10-2008)
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 3 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Part III
Information on Financial Account(s) Owned Jointly
Form TD F 90-22.1
Page Number
Complete a Separate Block for Each Account Owned Jointly
of
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
6
Last Name or Organization Name
Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
23 Country
24 Number of joint owners for this account 25 Taxpayer Identification Number of principal joint owner, if known. See instructions
26 Last Name or Organization Name of principal joint owner
27 First Name of principal joint owner, if known
28 Middle initial, if
known
29 Address (Number, Street, Suite or Apartment) of principal joint owner, if known
30 City, if known
31 State, if known
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
32 Zip/Postal Code, if known
16 Type of account a
33 Country, if known
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
23 Country
24 Number of joint owners for this account 25 Taxpayer Identification Number of principal joint owner, if known. See instructions
26 Last Name or Organization Name of principal joint owner
27 First Name of principal joint owner, if known
28 Middle initial, if
known
29 Address (Number, Street, Suite or Apartment) of principal joint owner, if known
30 City, if known
31 State, if known
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
32 Zip/Postal Code, if known
16 Type of account a
33 Country, if known
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
23 Country
24 Number of joint owners for this account 25 Taxpayer Identification Number of principal joint owner, if known. See instructions
26 Last Name or Organization Name of principal joint owner
27 First Name of principal joint owner, if known
28 Middle initial, if
known
29 Address (Number, Street, Suite or Apartment) of principal joint owner, if known
30 City, if known
31 State, if known
32 Zip/Postal Code, if known
33 Country, if known
Form
TD F 90-22.1
(Rev. 10-2008)
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 4 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Part IV
Information on Financial Account(s) Where Filer has Signature or Other
Authority but No Financial Interest in the Account(s)
Complete a Separate Block for Each Account
Form TD F 90-22.1
Page Number
of
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
6
Last Name or Organization Name
Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Bank b
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Last Name or Organization Name of Account Owner
36 First Name
39 City
Securities c
23 Country
35 Taxpayer Identification Number of Account Owner
37 Middle initial
40 State
38 Address (Number, Street, and Apt. or Suite No.)
41 Zip/Postal Code
42 Country
43 Filer’s Title with this Owner
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Bank b
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Last Name or Organization Name of Account Owner
36 First Name
39 City
Securities c
23 Country
35 Taxpayer Identification Number of Account Owner
37 Middle initial
40 State
38 Address (Number, Street, and Apt. or Suite No.)
41 Zip/Postal Code
42 Country
43 Filer’s Title with this Owner
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Last Name or Organization Name of Account Owner
36 First Name
39 City
Bank b
35 Taxpayer Identification Number of Account Owner
37 Middle initial
40 State
23 Country
38 Address (Number, Street, and Apt. or Suite No.)
41 Zip/Postal Code
42 Country
43 Filer’s Title with this Owner
Form
TD F 90-22.1
(Rev. 10-2008)
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 5 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Information on Financial Account(s) Where Corporate Filer Is Filing a
Consolidated Report
Complete a Separate Block for Each Account
Part V
Form TD F 90-22.1
Page Number
of
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
6
Last Name or Organization Name
Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
16 Type of account a
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Corporate Name of Account Owner
23 Country
35 Taxpayer Identification Number of Account Owner
38 Address (Number, Street, and Apt. or Suite No.)
39 City
40 State
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
41 Zip/Postal Code
16 Type of account a
42 Country
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Corporate Name of Account Owner
23 Country
35 Taxpayer Identification Number of Account Owner
38 Address (Number, Street, and Apt. or Suite No.)
39 City
40 State
15
Maximum value of account during calendar year reported
17
Name of Financial Institution in which account is held
18
Account number or other designation
20 City
41 Zip/Postal Code
16 Type of account a
42 Country
Bank b
Securities c
Other—Enter type below
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
21 State, if known
22 Zip/Postal Code, if known
34 Corporate Name of Account Owner
23 Country
35 Taxpayer Identification Number of Account Owner
38 Address (Number, Street, and Apt. or Suite No.)
39 City
40 State
41 Zip/Postal Code
42 Country
Form
TD F 90-22.1
(Rev. 10-2008)
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 6 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form TD F 90-22.1 (Rev. 10-2008)
General Instructions
Who Must File this Report. Each United States person who
has a financial interest in or signature or other authority over
any foreign 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 this report 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 currently examined
by Federal bank supervisory agencies for soundness and
safety 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 or employee
has NO personal financial interest in the account.
An officer or employee of a domestic corporation whose
equity securities are listed upon any United States national
securities exchange or which has assets exceeding $10
million and has 500 or more shareholders of record need not
file such a report concerning signature or other 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 or similar
responsible officer of the corporation that the corporation has
filed a current report, which includes that account. An officer
or employee of a domestic subsidiary of such a domestic
corporation need not file this report concerning signature or
other authority over the foreign financial account if the
domestic parent meets the above requirements, he has no
personal financial interest in the account, and he has been
advised in writing by the responsible officer of the parent that
the subsidiary has filed a current report which includes that
account. If a United States subsidiary is named in a
consolidated FBAR of the parent, the subsidiary will be
deemed to have filed a report for purposes of this exception.
An officer or employee of a foreign subsidiary more than
50% owned by such a domestic corporation need not file
this report concerning signature or other authority over the
foreign financial account if the employee or officer has no
personal financial interest in the account, and he has been
advised in writing by the responsible officer of the parent that
the parent has filed a current report which includes that
account.
General Definitions
United States Person. The term “United States person”
means a citizen or resident of the United States, or a person
in and doing business in the United States. See 31 C.F.R.
103.11(z) for a complete definition of “person.” The United
States includes the states, territories and possessions of the
United States. See the definition of United States at 31
C.F.R. 103.11(nn) for a complete definition of United States.
A foreign subsidiary of a United States person is not required
to file this report, although its United States parent
corporation may be required to do so. A branch of a foreign
entity that is doing business in the United States is required
to file this report even if not separately incorporated under
U.S. law.
Financial Account. This term 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 (including
mutual funds). The term also means any savings, demand,
Page
6
checking, deposit, time deposit, or any other account
(including debit card and prepaid credit card accounts)
maintained with a financial institution or other person
engaged in the business of a financial institution. Individual
bonds, notes, or stock certificates held by the filer are not a
financial account nor is an unsecured loan to a foreign trade
or business that is not a financial institution.
Account in a Foreign Country. A “foreign country” includes
all geographical areas located outside the United States. See
“United States Person” above 31 C.F.R. 103.11(nn) for a
definition of United States. The geographical location of the
account, not the nationality of the financial entity institution in
which the account is found determines whether it is in an
account in a foreign country. Report any financial account
(except a military banking facility) 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, or other office of a foreign
bank of other institution that is located in the United States.
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, is not an account in a foreign country.
Financial Interest. A financial interest in a bank, securities,
or other financial account in a foreign country means an
interest described in one of the following three 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.
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 or more than 50 percent of the voting power for all
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, taking into account any
special allocation agreement) or more than 50 percent of the
capital of the partnership; or (d) a trust in which the United
States person either has a present beneficial interest, either
directly or indirectly, in more than 50 percent of the assets or
from which such person receives more than 50 percent of
the current income.
3. 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 trust, or a person acting on behalf of a trust, that was
established by such United States person and for which a
trust protector has been appointed. A trust protector is a
person who is responsible for monitoring the activities of a
trustee, with the authority to influence the decisions of the
trustee or to replace, or recommend the replacement of, the
trustee.
Correspondent or “nostro” accounts (international
interbank transfer accounts) maintained by banks that are
used solely for the purpose of bank-to-bank settlement need
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 7 OF 10
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form TD F 90-22.1 (Rev. 10-2008)
not be reported on this form, but are subject to other Bank
Secrecy Act filing requirements. This exception is intended to
encompass those accounts utilized for bank-to-bank
settlement purposes only.
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
communication with the bank or other person with whom the
account is maintained, either directly or through an agent,
nominee, attorney, or in some other capacity on behalf of the
U.S. person, either orally or by some other means.
Filing Information—Do NOT file with your
Federal Income Tax Return
Page
7
Item 2. Check the appropriate box describing the filer. A
corporation which owns directly or indirectly more than a 50
percent interest in one or more other entities required to file
this Report will be permitted to file a consolidated report on
TD F 90-22.1, on behalf of itself and such other entities.
Check box “d” in Item 2 and complete Part V.
Consolidated reports should be signed by an authorized
official of the parent corporation. Trusts and other entities,
including tax-exempt organizations, should check box “e”
and describe the filer on the line following box “e.”
Item 3. A filer should provide the filer’s taxpayer identification
number. Generally this is the filer’s U.S. social security
number (SSN) or employer identification number (EIN).
Numbers should be entered with no spaces, dashes, or other
punctuation throughout this report. If the filer does not
possess such U.S. identification, the filer should complete
Item 4.
Explanations for Specific Items
Item 4. Complete Item 4 only if the filer has no U.S. taxpayer
identification number. Item 4 requires the filer to provide the
information about an official foreign government document
evidencing the filer’s nationality or residence. The filer should
write in the document number followed by the country of
issuance. The filer may check off the type of document. If
“other”’ is checked, the filer should write in the type of
document. For example, an individual who is not a U.S.
citizen would provide a passport number, the name of the
country of issuance, and check off “passport.”
Item 5. Enter the date of birth of the filer using the month,
day, and year convention.
Items 6, 7 and 8. Enter the name of the filer. An organization
should enter its name in the Last Name space.
Items 9, 10, 11, 12 and 13. Enter the address of the filer. An
individual filer residing in the United States should enter the
street address of filer’s United States residence, not a post
office box. An individual filer residing outside the United
States should enter the filer’s United States mailing address.
If the filer has no U.S. mailing address the filer may provide a
foreign address. An organization should enter its United
States mailing address.
Item 14. If the filer has a financial interest in 25 or more
foreign financial accounts, the filer should check the yes box,
sign and date the report (Items 44, 45 and 46) and leave
blank Part II (Continuation of Separate Accounts) or Part III
(Joint Accounts) of the report. If the group of entities covered
by a consolidated report has a financial interest in 25 or
more foreign financial accounts, the reporting parent
corporation need only complete Part V (for consolidated
reporting) Items 34 through 42, for the identity information of
the account owners, but need not complete the account
information. Detailed information about each account,
including all information called for on this report, must be
recorded and retained for five years from June 30 of the year
following the calendar year reported. Any person who reports
25 or more foreign financial accounts must provide all the
information omitted from Part II, III or V as appropriate.
Part I
Part II
Item 1. The Report of Foreign Bank and Financial Accounts
(FBAR) is an annual report. Enter the calendar year being
reported.
Item 15. Provide the maximum value of the account during
the calendar year being reported. The maximum value of an
account is the largest amount of currency or non-monetary
assets that appear on any quarterly or more frequent account
statement issued for the applicable year. If periodic account
statements are not 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
When and where to file. This report must be filed on or
before June 30 of the year following the calendar year
reported. The report is required annually. File by mailing this
report to the Department of the Treasury, Post Office Box
32621, Detroit, MI 48232-0621, or by hand-carrying it to any
local office of the Internal Revenue Service for forwarding to
the Department of the Treasury, Detroit, MI. Tax attaches are
located in the U.S. embassies in some countries. A filer can
receive instructions for verifying that a report has been filed
by calling the Detroit Computing Center Hotline at
1-800-800-2877.
Extensions of time to file federal tax returns do not extend
the time for filing this report. There is no extension of time
available for filing this report. If a delinquent FBAR is filed,
also attach a statement explaining the reason for the late
filing. See “When and where to file” (above) for filing
instructions.
An amendment of a previously filed FBAR is accomplished
by checking the “Amended” box in the upper right hand
corner of the first page of the form, making the needed
additions or corrections, and then stapling it to a copy of the
original form. Please also attach a statement explaining the
changes. See “When and where to file” (above) for filing
instructions.
Record Keeping Requirements. If this Report is required,
certain records must be retained. Such records must contain
the name in which each such account is maintained, the
number or other designation of such account, the name and
address of the foreign bank or other person with whom such
account is maintained, the type of such account, and the
maximum value of each account during the reporting period.
Retaining filed copies of this report will help to meet these
requirements. The records must be retained for a period of
five years and must kept at all times available for inspection
as provided by law.
Amendment of a previously filed FBAR is accomplished by
checking the “Amended” box in the upper right hand corner
of the first page of the form, making the needed additons
and corrections, and then stapling it to a copy of the original
report. See “When and where to file” (above) for filing
instructions.
4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM TD F 90-22.1, PAGE 8 OF 10 (PAGES 9 & 10 ARE BLANK)
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form TD F 90-22.1 (Rev. 10-2008)
Page
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 15, if the filer
had a financial interest in more than one account, each
account is to be valued separately in accordance with the
foregoing two paragraphs. If the filer had a financial interest
in one or more but fewer than 25 accounts, and is unable to
determine whether the maximum value of these accounts
exceeded $10,000 at any time during the year, complete Part
II, III, or V for each of these accounts and enter “value
unknown” in Item 15 for these accounts.
Item 16. Indicate the type of account. If “Other” is selected
describe the account.
Item 17. Provide the name of the financial institution with
which the account is held.
Item 18. Provide the account number which the financial
institution uses to designate the account.
Item 19—23. Provide the complete mailing address of the
financial institution where the account is located. If the
foreign state or postal code is not known leave them blank.
Part III
Item 24. Enter the number of joint owners for the account. If
the exact number is not known, provide an estimate. In
determining the number of joint owners, the filer is not
counted.
Items 25—33. Enter this identity information about the joint
owner. If there is more than one joint owner, enter the
identity information about the principal joint owner. The filer
may leave blank items for which no information is available.
A spouse having a joint financial interest in an account with
the filing spouse should be included as a joint account owner
in Part III of this report. The filer should write (spouse) on
Line 26 after the last name of the joint spousal owner. If the
only reportable accounts of the filer’s spouse are those
reported as joint accounts, the filer’s spouse need not file a
separate report. If the accounts are owned jointly by both
spouses, the filer’s spouse should also sign the report. See
the instructions for Item 44. If the filer’s spouse has a
financial interest in other accounts that are not jointly owned
with the filer or has signature or other authority over other
accounts, the filer’s spouse should file a separate report for
all accounts including those owned jointly with the other
spouse.
Part IV—No Financial Interest in Account
Items 34-42. You must provide the name, address, and
identifying number of the owner of a foreign financial account
over which you had signature or other authority but no
8
financial interest in the account. If there is more than one
owner of the account over which you have authority,
providethe information in Items 34-43 for the primary owner
for which you have authority. If you complete the account
information for more than one account of the same owner,
you need identify the owner only once. Write “Same Owner”
in Item 34 for the succeeding accounts of the same owner.
Item 43. Enter filer’s title for the position which gives him
authority over the account.
Part V—Consolidated Report for Corporate
Parent & Subsidiary Corporations
A corporation which owns directly or indirectly more than a
50 percent interest in one or more other entities required to
file this report will be permitted to file a consolidated report
on TD F 90-22.1, on behalf of itself and such other entities.
Check box “d” in Item 2 in Part I and complete Part V.
Items 34—42. You must provide the corporate name,
identifying number and address of the owner of the foreign
financial account as shown on the books of the financial
institution.
If you complete the account information for more than one
account of the same owner you need identify the owner only
once. Write “Same Owner” in Item 34 for the succeeding
accounts of the same owner.
Signatures
This report must be signed by the person named in Part I. If
the report is being filed on behalf of a partnership,
corporation, fiduciary or other legal entity, it must be signed
by an authorized individual. Consolidated reports should be
signed by an authorized official of the parent corporation.
Enter the title of the individual signing for a legal entity, such
as a corporation, which is shown as the filer. A spouse
included as a joint owner, who elects not to file a separate
report in accordance with the instructions in Part III, must
also sign this report. See the instructions for Part III.
Enter the title of the individual signing for a legal entity,
such as a corporation, which is shown as the filer. Leave
“Filer’s Title” blank if the filer is only reporting as an
individual. An individual filing because of a financial interest
in his individual accounts is filing as an individual. An
individual filing because of signature or other authority over a
foreign financial account is filing as an individual. If the filer
only has signature authority over the account, he should
enter his title in Part IV Item 43, Filer’s Title with this Owner,
to show his relationship to the account. Enter the actual date
signed.
Printed on Recycled Paper
| File Type | application/pdf |
| File Title | TDF 90-22.1 (Rev.October 2008) |
| Subject | Fillable |
| Author | SE:W:CAR:MP |
| File Modified | 2008-11-10 |
| File Created | 2008-11-06 |