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					                                                               Confidential




The Department of the Treasury requires that every US citizen or resident
with an interest in or an authority over foreign bank accounts, securities, or
other financial accounts that exceed $10,000 USD in aggregate value at
any time during the calendar year must report the relationship no later than
June 30 of the following year.

If you would like for us to complete and file the appropriate forms to disclose your
foreign bank account, please provide the following information:
1 Foreign Bank Account Information

Name of Bank

Address of Foreign Bank


 3     Country in which account is held

 4     Number of Foreign Financial Accounts

 5     Account number

 6     Type of account             Bank               Securities              Other

 7     Joint account           Yes               No
                           (if yes, please complete a and b)
       a. How many joint owners

       b. Taxpayer Identification Number of joint owner

 8     Maximum value of account during the calendar year

 9     Do you have a financial interest over account           Yes            No
                                                                      (If no, complete a-d)
           a   Person's name or Organization Name of Account Holder




           b   Taxpayer Identification Number




           c   Address
                                            Mailing Address

                               City              State             Zip Code
           d   Country




ExpatCPA.com                                             Phone: (714) 939-7670                Fax: (714) 939-1032
                                                              Confidential



2 Foreign Bank Account Information

Name of Bank

Address of Foreign Bank


 3    Country in which account is held

 4    Number of Foreign Financial Accounts

 5    Account number

 6    Type of account             Bank               Securities              Other

 7    Joint account           Yes               No
                          (if yes, please complete a and b)
      a. How many joint owners

      b. Taxpayer Identification Number of joint owner

 8    Maximum value of account during the calendar year

 9    Do you have a financial interest over account           Yes            No
                                                                     (If no, complete a-d)
          a    Person's name or Organization Name of Account Holder




          b    Taxpayer Identification Number




          c    Address
                                           Mailing Address

                              City              State             Zip Code
          d    Country




ExpatCPA.com                                            Phone: (714) 939-7670                Fax: (714) 939-1032
                                                              Confidential



3 Foreign Bank Account Information

Name of Bank

Address of Foreign Bank


 3    Country in which account is held

 4    Number of Foreign Financial Accounts

 5    Account number

 6    Type of account             Bank               Securities              Other

 7    Joint account           Yes               No
                          (if yes, please complete a and b)
      a. How many joint owners

      b. Taxpayer Identification Number of joint owner

 8    Maximum value of account during the calendar year

 9    Do you have a financial interest over account           Yes            No
                                                                     (If no, complete a-d)
          a    Person's name or Organization Name of Account Holder




          b    Taxpayer Identification Number




          c    Address
                                           Mailing Address

                              City              State             Zip Code
          d    Country




ExpatCPA.com                                            Phone: (714) 939-7670                Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032
                    Confidential




ExpatCPA.com   Phone: (714) 939-7670   Fax: (714) 939-1032

				
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