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forcement Network (FinCEN) May 2015 Record of Authorization to Electronically File FBARs (See instructions below for completion) Do not send to FinCEN. Retain this form for your records. ANASTAS20170001 The form 114a may be digitally signed Part I I Persons who have an obligation to file a Report
saction. If I am paying my New York State personal income taxes due by electronic funds withdrawal, I certify that the account holder has authorized the New York State Tax Department and its designated financial agents to initiate an electronic funds withdrawal from the financial institution account indicated on my 2017 electroni
forcement Network (FinCEN) May 2015 Record of Authorization to Electronically File FBARs (See instructions below for completion) Do not send to FinCEN. Retain this form for your records. TM form 114a may be digitally signed Part I I Persons who have an obligation to file a Report of Foreign Bank a
saction. If I am paying my New York State personal income taxes due by electronic funds withdrawal, I certify that the account holder has authorized the New York State Tax Department and its designated financial agents to initiate an electronic funds withdrawal from the financial institution account indicated on my 2017 electroni
cement Network (FinCEN) I May 2015 Record of Authorization to Electronically File FBARs (See instructions below for completion) Do not send to FinCEN. Retain this form for your records. ANASTAS20170001 The fomi 114a may be digitally signed Part I I Persons who have an obligation to file a Report
saction. If I am paying my New York State personal income taxes due by electronic funds withdrawal, I certify that the account holder has authorized the New York State Tax Department and its designated financial agents to initiate an electronic funds withdrawal from the financial institution account indicated on my 2017 electroni
Entities connected to both FinCEN and the New York State Tax Department

United States
LOCATIONLeon Black
PERSON
New York City
LOCATIONFiler
PERSON
New York
LOCATION
U.S. Treasury
ORGANIZATIONMaria Farmer
PERSON
New York State
LOCATION
Joi Ito
PERSONSpouse
ORGANIZATION
George W. Bush
PERSON
the Internal Revenue Service
ORGANIZATIONPreparer
ORGANIZATIONYonkers
LOCATION
NEW YORK NY
LOCATIONNew York State Sales Tax
ORGANIZATIONDOTTED LINE & MAIL UPPER PORTION
ORGANIZATIONPersonal Income Tax Information Center
ORGANIZATIONNYC-210
ORGANIZATION
Michael Cohen
PERSON