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complete the 3rd party preparer section on page one of the report. The E-tile system will auto complete item 46. NOTE: The FBAR must be received by the Department of the Treasury on or before April 17. 2018. An automatic extension to October 15.2018 is available. This report filed late for the following reason (Check only on
ion of the transmission, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicate
1 s 1T-201LATT Name(s) as shown on your Form IT•201 ANASTASIYA SIROOCHENKO A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200. 496. or section 195.20)? (see instruction
complete the 3rd party prepare, section on page one of the report. The E-tile system will auto complete item 46. NOTE: The FBAR must be received by the Department of the Treasury on or before April 17. 2018. An automatic extension to October 15.2018 is available. This report tiled late for the following reason (Check only on
ion of the transmission, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. tt applicable, I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicate
shown on your FormIT.201 ANASTASIYA SIROOCHENKO Your social security number. A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200. 496. or section 195.20)? (see instruction
complete the 3rd party preparer section on page one of the report. The E-tile system will auto complete item 46. NOTE: The FBAR must be received by the Department of the Treasury on or before April 17. 2018. An automatic extension to October 15.2018 is available. This report filed late for the following reason (Check only on
ion of the transmission, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. It applicable, I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicate
your Form IT•201 Your social security number ANASTASIYA SIROOCHENKO 9816 A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200, 496. or section 195.20)? (see instruction
Entities connected to both U.S. Treasury and Bribery Involving Public Servants

United States
LOCATION
New York
LOCATION
Joi Ito
PERSONMaria Farmer
PERSON
NEW YORK NY
LOCATION
New York City
LOCATION
the Internal Revenue Service
ORGANIZATION
New York State
LOCATIONUtilities
ORGANIZATIONChang
PERSON
FinCEN
ORGANIZATIONYonkers
LOCATIONSpouse
ORGANIZATIONFiler
PERSONthe U.S. Treasury Financial Agent
ORGANIZATIONPreparer
ORGANIZATIONC-EZ
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONSchedule SE
PERSONERO Signature
ORGANIZATION