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efta-efta01077866DOJ Data Set 9OtherTAX RETURN FILING INSTRUCTIONS
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DOJ Data Set 9
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efta-efta01077866
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TAX RETURN FILING INSTRUCTIONS
REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS - TAXPAYER
FOR THE YEAR ENDING
DECEMBER 31, 2013
Prepared for
illigilii
Prepared by
RAICH ENDE MALTER & CO., LLP
1375 BROADWAY
NEW YORK, NY 10018
Form must be
filed on
or before
RETURN FORM 114A TO US ON OR BEFORE JUNE 30, 2014.
Special
Instructions
THE TAXPAYER'S FORM 114 HAS BEEN PREPARED FOR ELECTRONIC FILI/
PLEASE SIGN, DATE, AND RETURN FORM 114A TO OUR OFFICE. WE WII
THEN TRANSMIT THE TAXPAYER'S FORM TO THE FINCEN.
G.
L
30009T
10-M13
EFTA01077866
Form 114a
Department of the Treasury
Financial Crimes Enforcement
Network (FinCEN)
October 2013
Record of Authorization to
Electronically File FBARs
(See instructions below for completion)
Do not send to FinCEN. Retain this form for your records.
LEONDBL20130001
Part I I Persons who have an obligation to file a Report of Foreign Bank and Financial Accounts)
1. Owner last name or entity s legal name
BLACK
2. Owner first name
LEON
3. Owner
D
4. Spouse last name (if jointly filing FBAR - see instructions below)
5. Spouse first name
6. Spouse s.
I/we declare that I/we have provided information concerning 16
(en er number of accounts) foreign bank and financial account(s) for the
tiling year ending December 31. 2 013 to the preparer listed in Part II; that this information is to the best of my/our knowledge true, correct.
and complete: that I/we authorize the preparer listed in Part II to complete and submit to the Financial Crimes Enforcement Network (FinCEN) a
Report of Foreign Bank and Financial Accounts (FBAR) based on the information that I/we have provided; and that I/we authorize the preparer
listed in Part II to receive information from FinCEN, answer inquiries and resolve issues relating to this submission. I/we acknowledge that,
notwithstanding this declaration, it is my/our legal responsibility. not that of the preparer listed in Part II, to timely file an FBAR if required by law
to do so.
7. Owner signature (Authorized representative if entity)
8. Date
9. Owner or entity TIN
10. TIN
a
type b
c
I I
II
C
EIN
SSN/ITIN
Foreign
MM DD
YYYY
11. Spouse signature
12. Date
13. Spouse TIN
14. TIN
a I I EIN
type b C
SSN/ITIN
c C
Foreign
MM DD
YYYY
Part III Individual or Entity Authorized to File FBAR on behalf of Persons who have an obligation to file.
15. Preparer last name
TURRIN
16. Preparer first name
THOMAS
17. Preparer M.
18. Preparer PTIN
19. Address
1375 BROADWAY
20. City
NEW YORK
21. State
NY
22 ZIP/postal code
10018
23. Country
code
US
24. Preparer's (item 15) employer's (Entity) name
ICH ENDS HALTER & CO., LLP
25. Employer EIN
26. Preparer's signature
Instructions for completing the FBAR S gnature Authorization Record
This record may be completed by the individual or entity granting such authorization (Part l) OR the individuaVentity authorized to perform such
services. The completed record must be signed by the individual(s)/entity granting the authorization (Part I) and the individuaVeMity that will file the
FBAR. The Preparer/filing entity must be registered with FinCEN BSA EFile system. (See http://bsaefiling.fncentreas.gov/main.html for registration).
Read and complete the account owner statement in Part I.
To authorize a third party to file the Foreign Bank and Financial Accounts Report (FBAR). the account owner should complete Part I, items 1 through
3 (as required), sign and date the document in Part I, items 7/8 and complete items 9 and 10.
Accounts Jointly Owned by Spouses (see exceptions in the FBAR instructions)
If the account owner is filing an FBAR jointly with his/her spouse, the spouse must also complete Part I, items 4 through 6. The spouse must also
sign and date the report in items 11/12. and complete items 13 and 14. A third party preparer may be one of the spouses of the jointly owned
foreign account. In this case, both spouses must complete Part I of form 114a in its entirety. The third party preparer (spouse) that will file the FBAR
on behalf of both spouses will complete Part II in its entirety (do not use such terms as see above, or same as item number 4.
Complete Part II, items 15 through 18 with the preparer's information. The address, items 19 through 23. is that of the preparer or the preparer's
employer if the prepare( is an employee. Record the employer's information (if any) in items 24 and 25. If the preparer does not have a PTIN, leave
item 18 blank. The third party prepare( must sign in item 26 of Part II indicating that the FBAR will be filed as directed by the authorizing authority.
The person(s) listed in Part I, and the person listed in Part II as authorized to file on behalf of the person(s) listed in Part I, should retain copies
of this record of authorization and the filing itself, both for a period of 5 years. See 31 CFR 1010.430(d).
DO NOT SEND THIS RECORD TO FinCEN UNLESS REQUESTED TO DO SO.
N-01-13
16430626 133415 T-1009
7
2013.04000 BLACK, LEON
Rev. 10.4 July 11, 2013
T-10093
EFTA01077867
FINANCIAL CRIMES
ENFORCEMENT NETWORK
BSA E-Filing - Report of
Foreign Bank and Financial
Accounts (FBAR)
LEONDBL20130001
Filing Name LEON D. BLACK
Submission Type NEW
PIN NOT REQUIRED
Version Number: 1.1
FInCEN Form 114
OMB Control Number: 1506-0009
Effective January 1, 2014
Check here
if this report is submitted by an authorized third party, and complete the 3rd party preparer section on page one of the
report. The E-file system will auto complete item 46.
NOTE: The F8AR must be received by the Department of the Treasury on or before June 30th of the year immediately following the
calendar year being reported. The June 30th filing date may not be extended.
This report filed late for the following reason (Check only one):
a.
Forgot to file
b.
c.
d.
e.
g
h
I=1 Did not know that I had to file
I=1 Thought account balance was below reporting threshold
I=1 Did not know that my account qualified as foreign
I=1 Account statement not received in time
I=1 Account statement lost (Replacement requested)
Late receiving missing required account information
Unable to obtain joint spouse signature in time
Unable to access 8SA Efiling system
Other (please provide explanation below)
321151
08.13.13
1
16430626 133415 T-1009
2013.04000 BLACK, LEON
T-10093
EFTA01077868
FinCEN Form 114
cieewerecii a the Treasoy
REPORT OF FOREIGN BANK
AND FINANCIAL ACCOUNTS
1 This report is for calendar
year ended 12/31
O&
no 1506-0009
tRev. September 20131
Do NOT file with your Federal Tax Return
2013
Do not use previous editions of this form
Ameded
I Part I I
Filer info matron
LEONDBL20130001
2 Type of filer
a LM Individual
b El Partnership c Q
Corporation d El Consolidated e
Fiduciary or other • Enter type
3 U.S. Taxpayer Identification Number
If filer has no U_S Identification
3a TIN type
SSN/ITIN
El EIN
4 Foreign identification (Complete only if item 3 is not applicable)
5 Individual's date of birth
MM/DD/YYYY
a Type' El Passport C
Foreign TIN El Other
b Number
c Country of Issue
number complete item 4
6 Last name or organization name
7 First name
BLACK
LEON
8 Middle initial 8a Suffix
D
9 Mailing address (number. street. and apt. or suite no.)
10
14 a) Does the filer have a financial interest in 25 or more financial accounts?
Yes C
Enter number of accounts
Do not complete Part II or Part III, but maintain records of the information.
No XI
b) Does the filer have signature authority over but no financial interest in 25 or more financial accounts?
Yes
Enter number of accounts
Comp. Part IV, items 34 through 43 for each person on whose behalf the filer has sign. authority.
No IXI
Part III
Information on financial account(s) owned separately
15 Maximum value of account during calendar year
15a Amount 16 Type of account aLXJ Bank 1)1_1 Securities cLJ Other • Enter type below
unknown
917,558.
17 Name of financial institution in which account is held
BANK OF SCOTLAND
18
r other designation
gna
9 Maifi
address number. street. apt. or suite no.) of financial institution in which account is held
re
44a Check here I I if this report is completed by a third party preparer and complete the third ,arty preparer section.
44 Filer signature
The meal wi be Sarawak,
w
47 Preparer's last name
URRIN
52 Contact phone no.
12-944-4433
45 Filer title, if not reporting a personal account
Third Party
Preparer
Use Only
48 First name
THOMAS
52a Ext.
Irt.A3 Firm's name
ICH ENDE MALTER &
50 Checker if
seltemployed
46 Date (MWDp
This dale willa=en
the
FEAR
eloc •nl
51a TIN type L.I PTIN
SSN/ITIN
Foreign
54a TIN type LXJ EIN
El Foreign
55 Mailing address (number, street, apt. or suite no.) 56 City
57 State
56 ZIP/Postal Code
59 Country
375 BROADWAY
NEW YORK
NY
10018
US
This form should e used to report a financial interest in, signature authority, or other authority over one or m re financial accounts in foreign countries, as required by
the Department of the Treasury Regulations 31 CFR 1010.350. No report is required if the aggregate value of he accounts did not exceed $10,000. See instructions
for definitions.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
Pursuant to the requirements of Pubic Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on FinCEN Form 114 in
accordance with 5 USC 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 1010.350. 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 5600,000 and imprisonment of not more than five years, are provided for failure to file a report, for failure to 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 1010.350. 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 60 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 Financial Crimes Enforcement Network, M. Box 39, Vienna, VA 22183, Attn: Office of Regulatory Policy.
Rev 5.7 • 6/3/2013
323141 10.30.13
16430626 133415 T-1009
2
2013.04000 BLACK, LEON
T-10093
EFTA01077869
rPart II
Continued - Information on Financial Account(s) Owned Separately
Complete a Separate Block for Each Account Owned Separately
FORM 114
Page Number
1
of 3
1 Filing for calendar
year
2013
3-4 Check appropriate Identification Number
IM Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
6 Last Name or Organization Name
BLACK
15 Maximum value of account during calendar year 15a Amount1133n
6,050,010.
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
1
16 Type of account a IX' Bank b L1 Securities e LJ Other - Enter type below
15 Maximum value of account during calendar year
sa Amount Unknovm 18 Type of account a ti
Bank b
Securities c
Other - Enter type below
947,856.
ILI
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
20
15 Maximum value of account during calendar year 15a Anount Unknovm 16 Type of account a LXJ Bark b LJ Securities e U
Other - Enter type below
964,177.
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
18 Account number or other designation
19 Mailing Address (Number, Street Suite Number) of financial institution in which account is held
20
O
16 Maximum value of account during calendar year 15a
Amount Unknowt 16 Type of account a
Bank b
Securities c
Other - Enter type below
17,619.
0
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
18 Account number or other desi nation
19 Mailin Address Number Stree Suite Number of financial institution in which account is held
20
16 Maximum value of account during calendar year the Arncunt Unknown 16 Type of account a Lx.l Bark b
Securities c LJ Other - Enter type below
138,667.
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
20
16 Maximum value of account during calendar year isa Amount Unknarn 18 Type of account a
Bank b LI Securities c LI Other - Enter type below
64,575.
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
18 Account number or other designation
119 Mailing Address (Number, Street Suite Number) of financial institution in which account is held
320015 09.24.13
16430626 133415 T-1009
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2013.04000 BLACK, LEON
T-10093
EFTA01077870
rPart II
Continued - Information on Financial Account(s) Owned Separately
Complete a Separate Block for Each Account Owned Separately
FORM 114
Page Number
2 of 3
1 Filing for calendar
year
2013
3-4 Check appropriate Identification Number
IM Taxpayer Identification Number
0
Foreign Identification Number
Enter identification number here:
6 Last Name or Organization Name
BLACK
15 Maximum value of account during calendar year
28,163.
sa
ml unknown 16 Type of account a IX' Bank b LJ Securities e LJ Other - Enter type below
17 Name of Financial Institution in which account is held
BANK OF SCOTLAND
16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a
Bank b
Securities c
Other - Enter type below
4,614.
17 Name of Financial Institution in which account is held
LA CAIXA
20
15 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a
Bark b LJ Securities e LJ Other - Enter type below
152,939.
17 Name of Financial Institution in which account is held
COMMERZBANK AG
18 Account number or other desi nation
19 Mailin Address Number. Street. Suite Number of financial institution in which account is held
20
16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a
Bark b
Securities c
Other - Enter type below
874,673.
17 Name of Financial Institution in which account is held
SOCIETE GENERALE
18 Account number or other desi nation
in in which accoun
held
O
15 Maximum value of account during calendar year
sa
nt Unknown 18 Type of account a tY Bank b
Securities c
Other - Enter type below
16,177.
0
17 Name of Financial Institution in which account is held
COMMONWEALTH BANK OF AUSTRALIA
18 Account number or other designation
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
16 Maximum value of account during calendar year
5a Amount Unknown, 18 Type of account a
0
44,086.
Bark b
Securities c
Other - Enter type below
17 Name of Financial Institution in which account is held
BANK OF TOKYO-MITSUBISHI UFJ LTD
18 Account number or other designation
j19 Mailing Address (Number. Street Suite Number) of financial institution in which account is held
520015 oe.es.i
4
16430626 133415 T-1009
2013.04000 BLACK, LEON
T-10093
EFTA01077871
rPart II
Continued - Information on Financial Account(s) Owned Separately
Complete a Separate Block for Each Account Owned Separately
FORM 114
Page Number
3
of 3
1 Filing for calendar
year
2013
3-4 Check appropriate Identification Number
IM Taxpayer Identification Number
Foreign Identification Number
Enter identification number here:
6 Last Name or Organization Name
BLACK
15 Maximum value of account during calendar year
44,483.
17 Name of Financial Institution in which account is h Id
BANK OF TOKYO-MITSUBISHI UFJ LTD
18 Account number or other designation
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
.15a Amount tin
O
16 Type of account a LXJ Bank b Li
Securities e Li
Other - Enter type below
15 Maximum value of account during calendar year
5,a Amount Unknotem 16 Type of account a
84,796.
0
17 Name of Financial Institution in which account is held
CREDIT SUISSE AG
Bank b
Securities e
Other - Enter type below
20
16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a LX.I Bank b U
Securities c LJ Other - Enter type below
1.
17 Name of Financial Institution in which account is held
BANK OF TOKYO-MITSUBISHI UFJ, LTD
18 Account number or other deli' nation
Mailin Address Number Stree Suite Number of financial institution in which account is held
16
Other -Enter type below
17 Name of Financial Institution in which account is held
18 Account number or other designation
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20 City
21 State. if known
15 Maximum value of account during calendar year lea Amount Unkn
O
[Lj
22 ZIP/Postal Code. if known
23 Country
16 Type of account a Li Bank b
Securities c Li
Other - Enter type below
17 Name of Financial Institution in which account is held
18 Account number or other designation
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20 City
21 State. if known
22 ZIP/Postal Code, if known
23 Country
15 Maximum value of account during calendar year 1$8 Amount Unknown
O
16 Type of account a
Bank b
Securities c L.J Other - Enter type below
17 Name of Financial Institution in which account is h Id
18 Account number or other designation
19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held
20 City
21 State, if known
22 ZIP/Postal Code, if known
23 Country
320015 09.24.13
5
16430626 133415 T-1009
2013.04000 BLACK, LEON
T-10093
EFTA01077872
Technical Artifacts (10)
View in Artifacts BrowserEmail addresses, URLs, phone numbers, and other technical indicators extracted from this document.
Phone
1506-0009Phone
16430626Phone
944-4433SWIFT/BIC
ACCOUNTSSWIFT/BIC
COMMERZBANKSWIFT/BIC
ENFORCEMENTSWIFT/BIC
GENERALESWIFT/BIC
SCOTLANDSWIFT/BIC
TAXPAYERURL
http://bsaefiling.fncentreas.gov/main.htmlForum Discussions
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