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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
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
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
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
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
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 FinCEN and Bribery Involving Public Servants

United States
LOCATION
New York City
LOCATIONFiler
PERSON
New York
LOCATION
U.S. Treasury
ORGANIZATIONMaria Farmer
PERSONSpouse
ORGANIZATION
Joi Ito
PERSONPreparer
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONthe Foreign Bank and Financial Accounts Report
ORGANIZATIONFBAR S gnature
ORGANIZATION
New York State
LOCATIONthe U.S. Treasury Financial Agent
ORGANIZATIONConservation Reserve Program
ORGANIZATIONConservation Reserve
ORGANIZATIONERO Signature
ORGANIZATIONC-EZ
ORGANIZATIONJurat/Disclosure
ORGANIZATIONForeign Bank
ORGANIZATION