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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
le. if not reporting a personal account 46 Dattlate wlepa Mn the HMO le aottonelIteignel Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 MI 50 Check LJ if selfomployedp0096 51 TIN 2062 51a TIN type I XI PTIN 0 SSNATIN Foreign 52 Contact phone no. 212-
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
sonal account 146 Date (MWDD Ma date will auto.I N Men the FBAR is ay.t.tionaiit ore, Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 M 50 Check if self -employed x 51a TIN type I I PTIN SSNATIN Foreign 52 Contact phone no. sza Ext. 53 Firm's name
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
ing a personal account 146 Date (MM/DD Ma date will auloitnneMn the nswisaanuol el gnea Third Party Preparer Use Only 47 Preparer's last name WEISS 48 First name DAVID 49 MI 50 Checks I if so-mow/3O)00962062 51 TIN 51a TIN type I XI PTIN SSNATIN Foreign 52 Contact phone no. 212-695-577
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