2012 OVDP Submission Requirements

Form

14454

(January 2013)

Department of the Treasury–Internal Revenue Service

OMB Number
1545-XXXX

Offshore Voluntary Disclosure
Program Letter Attachment

Please ensure all pages of Form 14454 include your name, the last four digits of your taxpayer identification number, the name of the
foreign financial institution, and the account number for which you are responding.
For each foreign financial account of which you have control or are a beneficial owner, provide the following information.
Taxpayer Name

Last Four Digits of Taxpayer
Identification Number

1a. Foreign Financial Institution Name

1b. Account Number

2. Country, including address, where the account was established (If different, country, including address, where

3. Date the account was opened

account is currently located)

4a. Is the account still open?
Yes
No
4b. If “No,” when was the account closed
5a. Identify the individual(s) and/or organization(s) (e.g., banks, independent financial advisors, trust or corporate service providers) who advised or assisted you in
opening and using/maintaining the account.

5b. Explain all communications you had regarding the opening and use/maintenance of the account. Identify the individuals (whether affiliated with the
foreign financial institution or independent from the financial institution), dates, and form (e.g., face-to-face meeting, phone, email, fax, etc.) of the communication.

5c. Did you hold any meetings or receive any phone calls, faxes, emails, or any other communications from these
individuals to you in the U.S.?

Yes

No

Yes

No

If “Yes,” where
5d. Are any of the individuals a business person (advisor), accountant, attorney, or return preparer in the U.S.?
If “Yes,” identify which organization(s)
6a. What documentation was received by or shown to you regarding opening and maintenance of the account (e.g., account statements, account opening
documents, etc.)

6b. Did you retain any of the documents?

Yes

No

7. Were you able to make deposits to or withdrawals from your account through the use of a U.S. domestic branch
office of the foreign financial institution?

Yes

No

8a. Did you make deposits (beyond the initial opening deposit) or withdrawals from the account?

Yes

No

9. Were you able to access funds in your offshore account by the use of wire transfers made into the U.S.?

Yes

No

10. Were you able to access funds in your offshore account through the use of a debit or credit card?

Yes

No

If “Yes,” identify the documents retained
If “No,” explain why you did not retain them

If “Yes,” respond to the following:
8b. How did you make a deposit or withdrawal (e.g., in person, computer, phone, use of third-party, etc.)
8c. What form did the deposits or withdrawals take (e.g., cash, check, wire, traveler's check, etc.)
8d. What documents did you receive when a deposit or withdrawal was made (e.g., receipt, debit memo, credit memo, etc.)

11. Are there other individuals affiliated with the account?
Yes
No
If “Yes,” identify each person affiliated with the account, including the nature of their relationship to the account (e.g., owner, beneficial owner, power of
attorney, etc.)

Catalog Number 61606G

www.irs.gov

Form 14454 (1-2013)

Form

14454

(January 2013)

Department of the Treasury–Internal Revenue Service

OMB Number
1545-XXXX

Offshore Voluntary Disclosure
Program Letter Attachment

Taxpayer Name

Last Four Digits of Taxpayer
Identification Number

1a. Foreign Financial Institution Name

1b. Account Number

12a. Is an entity affiliated with the account?

Yes

No

If “Yes,” respond to the following:
12b. Identify the entity, including the nature of its relationship to the
account (e.g., nominee owner, beneficial owner, power of attorney, parent

12c. Identify the entity's formal structure

12e. Identify the individual(s) and/or organization(s) (e.g., the foreign bank,

12f. Identify the individual(s) or organization(s) that managed the entity

(e.g., corporation foundation, trust, etc.)

entity of corporate account holder, etc.)

an outside professional, etc.) who suggested forming the entity and who
formed the entity

12d. Identify the country where
the entity was organized

12g. Is the entity still in existence?

Yes

No

12h. 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?

Yes

No

If “Yes,” identify the individual(s)
12i. Was a U.S. bank, brokerage firm or other financial services company involved in setting up the entity or in advising
its use?

Yes

No

13. With respect to communications you had about your foreign financial account, provide the following:
13a. Did a representative of the foreign financial institution or advisor visit you in the United States regarding the
offshore account?

Yes

No

13b. Did a representative of the foreign financial institution or advisor suggest to you the use of offshore accounts,
offshore investments, offshore entities, or particular foreign countries as a way of avoiding the disclosure of your
ownership of the account or avoiding taxes?

Yes

No

13c. Did a representative of the foreign financial institution or advisor suggest to you the use of practices, such as
holding mail at the institution, using prepaid phone cards, using credit or debit cards, communicating via fax or
email, bank storage of account documentation, or conducting face-to-face meetings, to avoid the disclosure of your
ownership of the account?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If “Yes,” identify the bank, firm, or company

13d. Did a representative of the foreign financial institution, one of its U.S. subsidiaries, or advisor provide services in
the U.S. related to offshore accounts (e.g., facilitating opening accounts, reviewing account activity, forwarding account
statements, providing investment and/or tax advice, etc.)?
13e. Did a representative of the foreign financial institution or advisor suggest you meet in a jurisdiction outside the U.S.
and other than where the institution is located?
13f. Did a representative of the foreign financial institution or advisor suggest you either not file a voluntary disclosure
with the IRS or repatriate the foreign funds into the U.S.?
13g. Did an advisor or other person attempt to influence you to move funds from one foreign financial institution to
another or from one foreign country to another?

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.
Catalog Number 61606G

www.irs.gov

Form 14454 (1-2013)