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pdf14454
Form
(December 2017)
Department of the Treasury–Internal Revenue Service
Attachment to Offshore Voluntary Disclosure Letter
OMB Number
1545-2241
(One attachment is required for each financial institution)
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. Address, including country, where the account was established (If different, address,
3. Date the account was opened DO NOT LEAVE BLANK
(if unsure, please estimate)
including country, where account is currently located)
4a. Is the account still open?
Yes
No
4b. If “No,” when was the account closed
5. Identify the individual(s), affiliates 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. Include contact information for individual(s), affiliates, and/or organization(s)
6a. 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.
6b. Any meetings, phone calls, faxes, emails, or any other communications from these individuals to you in the U.S.?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” where
6c. Are any of the individuals a business person (advisor), accountant, attorney, or return preparer in the U.S.?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” identify which organization(s)
7. With respect to communications you had about your foreign financial account, provide the following:
7a. Did a representative of the foreign financial institution or advisor visit you in the United States regarding the offshore account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7b. 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?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” provide the dates and locations for all meetings
Catalog Number 61606G
www.irs.gov
Form 14454 (Rev. 12-2017)
Page 2
Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
7c. 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-toface-meetings, to avoid the disclosure of your ownership of the account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7d. 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.)?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7e. 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?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” provide the dates and locations for all meetings
7f. 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.?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
7g. 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?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
8a. What documentation was received by or shown to you regarding opening and maintenance of the account (e.g., account statements, account opening
documents, etc.)?
8b. Who showed you the documentation and when?
8c. Did you retain any of the documents?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
If “Yes,” identify the documents retained
If “No,” explain why you did not retain them
9. 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?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Catalog Number 61606G
www.irs.gov
Form 14454 (Rev. 12-2017)
Page 3
Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
10a. Did you or someone on your behalf make deposits (beyond the initial opening deposit) to the account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Entity name
Telephone number
Address
If “Yes,” respond to the following:
10b. How did you make a deposit (e.g., in person, online, phone, ATM, use of third-party, etc.)?
10c. What form were the deposits in (e.g., cash, check, wire, traveler’s check, etc.)?
10d. What documents did you receive when a deposit was made (e.g., receipt, credit memo, etc.)?
10e. If funds were transferred from other financial institutions, provide the following information (if more space is needed, attach additional pages)
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
11a. Did you or someone on your behalf withdraw money from the account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Entity name
Telephone number
Address
If “Yes,” respond to the following:
11b. How were the funds withdrawn (e.g., in person, online, phone, ATM, use of third-party, etc.)?
11c. What form were the withdrawals in (e.g., cash, check, wire, debit, etc.)?
11d. What documents were received when a withdrawal was made (e.g., receipt, debit memo, etc.)?
11e. If funds were transferred to other offshore financial institutions, provide the following information (if more space is needed, attach additional pages)
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
12a. Did you move any funds into the United States during the life of the account?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Entity name
Telephone number
Address
If “Yes,” respond to the following:
12b. In what form did you move the funds (e.g., cash, check, wire, bank checks, etc.)?
12c. Did you engage in any transactions or series of transactions or use any third parties or other methods or schemes to move the money back into the
United States (e.g. loans, business invoices, other entities, third parties, etc.)? If yes, explain and identify all individuals and entities involved
Catalog Number 61606G
www.irs.gov
Form 14454 (Rev. 12-2017)
Page 4
Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
12d. Provide the following information about the U.S. Financial Institution(s) to which the funds were transferred (if more space is needed, attach additional
pages)
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
13a. Did you move any funds to a country outside the jurisdiction of the country where the account was held?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities
Yes
No
Entity name
Telephone number
Address
13b. If funds were transferred to other financial institutions, provide the following information:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
14a. Are there other individuals affiliated with the account(s)?
Taxpayer
Yes
No
Spouse
Yes
No
14b. If “Yes,” identify each person affiliated with each account, including the nature of their relationship to the account (e.g., owner, beneficial owner, power of
attorney, signatory authority, etc.)
15a. Is an entity affiliated with the account(s)?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” respond to the following for each entity:
15b. Identify the entity, including the nature of its relationship to the account (e.g., nominee owner, beneficial owner, power of attorney, parent entity of corporate
account holder, etc.)
15c. Identify the entity’s formal structure (e.g., corporation, foundation, trust, etc.)
15d. Identify the country where the entity was organized
15e. Identify the individual(s) and/or organization(s) (e.g., the foreign bank, an outside professional, etc.) who suggested forming the entity and who formed the
entity
15f. Identify the individual(s) or organization(s) that managed the entity
15g. Is the entity still in existence?
Taxpayer
Yes
No
Spouse
Yes
No
Catalog Number 61606G
www.irs.gov
Form 14454 (Rev. 12-2017)
Page 5
Taxpayer Name
Last Four Digits of Taxpayer Identification Number
1a. Foreign Financial Institution Name
1b. Account Number
15h. 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?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” identify the individual(s)
15i. Was a U.S. bank, brokerage firm or other financial services company involved in setting up the entity or in advising its use?
Taxpayer
Yes
No
Spouse
Yes
No
If “Yes,” identify the bank, firm, or company
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. However, if you choose to apply, you are required to provide all information requested on the offshore voluntary disclosure letter, as well as
any necessary attachments.
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 (Rev. 12-2017)
| File Type | application/pdf |
| File Title | Form 14454 (Rev. 12-2017) |
| Subject | Attachment to Offshore Voluntary Disclosure Letter |
| Author | SE:CI:IO:IFOE |
| File Modified | 2017-12-19 |
| File Created | 2017-12-19 |