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mated tax, and the financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment I must contact the U.S. Treasury Financial Agent at 1-888-3534537. Payment cancellation
lost (Replacement requested) Late receiving missing required account information Unable to obtain joint spouse signature in time Unable to access BSA Efiling system Other (please provide explanation below) 773151 05-21-17 EFTA00792088 FinCEN Form 114 REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS Do
mated tax, and the financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellatio
lost (Replacement requested) Late receiving missing required account information Unable to obtain joint spouse signature in time Unable to access BSA Efiling system Other (please provide explanation below) 773151 05-21-17 EFTA00792178 FinCEN Form 114 REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS Do
mated tax, and the financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellatio
lost (Replacement requested) Late receiving missing required account information Unable to obtain joint spouse signature in time Unable to access BSA Efiling system Other (please provide explanation below) 773151 05-21-17 EFTA00792000 FinCEN Form 114 REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS Do
Entities connected to both the U.S. Treasury Financial Agent and BSA Efiling

U.S. Treasury
ORGANIZATIONSpouse
ORGANIZATIONC-EZ
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONSchedule SE
PERSON
FinCEN
ORGANIZATIONFiler
PERSON
United States
LOCATIONERO Signature
ORGANIZATIONUtilities
ORGANIZATIONJurat/Disclosure
ORGANIZATIONPreparer
ORGANIZATION
Joi Ito
PERSONFBAR S gnature
ORGANIZATIONthe Foreign Bank and Financial Accounts Report
ORGANIZATIONForeign Bank
ORGANIZATIONConservation Reserve Program
ORGANIZATIONConservation Reserve
ORGANIZATIONJohn O. Smith
PERSONthe New York State Tax Department
ORGANIZATION