DS9 Document EFTA01128890

Off Voluntary Disclosures If taxpayer has domestic issues on please have them apply for a traditional voluntary disclosure. Date: Internal Revenue Service Voluntary Disclosure Coordinator 1-D04-100 2970 Market Street Philadelphia, PA 19104 Re: Taxpayer Name Tax Identification NUIllher Taxpayer Date of Birth Taxpayer Address Dear Voluntary Disclosure Coordinator: To assist in a timely determination of my acceptance into the Voluntary Disclosure Program, (for Voluntary Disclosures involving offshore accounts), I have addressed all of the following items: I. Please include: o Complete name: o Social Security Number: o Date of Birth: o Address: o Passport Number (and Country): o Current Occupation: 2. Taxpayer Representative and his/her contact information. 3. Type of Voluntary Disclosure K Offshore Only K Offshore and Domestic Page 1 of 4 EFTA01128890 4. Identify the source of the funds. 5. Have any of the offshore accounts you are disclosing been identified by the IRS as ineligible for this program? K Yes K No 6. Has anyone, including a foreign government or a foreign financial institution, advised you that your offshore account records, which are the subject of this voluntary disclosure, were susceptible to being turned over to the US Government pursuant to an official request? K Yes K No o If yes, did you or anyone on your behalf submit documents in opposition? K Yes K No o If yes, were copies of those documents provided to the Attorney General of the United States as required by 18 USC § 3506? K Yes K No 7. Disclose if you or any related entities are currently under audit or criminal investigation by the Internal Revenue Service or any other law enforcement authority. o Has the IRS notified you that it intends to commence an examination or investigation? K Yes K No o Are you under criminal investigation by any law enforcement authority? El Yes El No If yes, please explain 8. Do you believe that the IRS has obtained information concerning your tax liability? K Yes K No Page 2 of 4 EFTA01128891 If yes, please specify. 9. Please check the box to estimate the annual range of the highest aggregate value of your offshore accounts. HiahestAnareaate Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year AccountlAsset Value $0 to $100,000 K n n K Li • man to $1,000,000 n El K El U • $l coo 000tos2.50N): EJ ID LI Li O O II E_H. $2 see 000 to $10 000.:a l:l l:lnl:l_ 0 0 0 K ____!_ K 0 $10 000 000 t ,S)0SI:nO O 000 Greater than $100,000,000 0 10. Please check the box to estimate the range of potential total unreported income from the offshore account(s) during each disclosure period. Estimated Total Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Unreported Income $0 to $100.000 • CI CI $l 00 000 to $1 000 000 CI K CI CI 0 • • . $1,000,000 to $2,500,000 CI CI • • $2 500 000 to $10,000.000 CI CI • Greater than $10.000.000 CI • • • • For each foreign financial account of which you have control or are a beneficial owner, complete the attached form entitled "Attachment to Offshore Voluntary Disclosures Letter." Please ensure all pages of the attachment 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. To be included with all letters: By signing this document, I certify that I am willing to continue to cooperate with the Internal Revenue Service, including in assessing my income tax liabilities and making good faith arrangements to pay all taxes, interest, and penalties associated with this voluntary disclosure. Under penalties of perjury, I declare that I have examined this document, all attachments, and accompanying statements, and to the best of my knowledge and belief, they are true, correct, and complete. Signature of Taxpayer Print Name Date Page 3 of 4 EFTA01128892 Signature of Taxpayer's Spouse Print Name Rite IRS reserves the right to make further contacts with the taxpayer to eta rit. his/her submission. Page 4 of 4 EFTA01128893