4
Shared Docs
4
Same-Page
4 / 4
Mentions
gning this Tax Return and Electronic Funds Withdrawal Consent, it applicable, by entering my Self-Select PIN below. Taxpayer's PIN: Date 09122018 Spouse's PIN: 719986 044)I.17 EFTA00792091 Form 114a Department of the Treasury Financial Crimes Enforcement Network (FinCEN) May 2015 Record of Au
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
Information. 2017 Submission Identification Number (SID) Taxpayer's name ANASTASIYA SIROOCHENKO Social security number ***4**4. Spouses name Spouse's social secure num er . . liPart rl Tax Return Information - Tax Year Ending December 31, 2017 (Whole dollars only) 1 Adjusted gross income (F
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
ormation. 2017 Submission Identification Number (SID) Taxpayer's name ANASTASIYA SIROOCHENKO Spouses name Social security number ***4 "4-9816 Spouse's social security number IPartI Tax Return Information - Tax Year Ending December 31,2017 (whole dollars only) 1 Adjusted gross income (Form 1040,
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
y Tax Credit, or Ny0210, Claim for New York City School Tax Credit. For returns filed jointly, both spouses must complete and sign Form TR-5791T. Spouse's name: (Jointly filed return only) 588351 11.2545 EROs must complete Part C prior to transmitting electronically filed income tax returns (Forms
eturn and any authorized payment transaction. If I am paying my New York State personal income taxes due by electronic funds withdrawal, I authorize 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 2015 electroni
Entities connected to both Spouse and the New York State Tax Department

New York City
LOCATION
Joi Ito
PERSON
United States
LOCATION
New York
LOCATION
George W. Bush
PERSON
NEW YORK NY
LOCATION
New York State
LOCATION
U.S. Treasury
ORGANIZATIONPreparer
ORGANIZATIONMaria Farmer
PERSON
the Internal Revenue Service
ORGANIZATIONUtilities
ORGANIZATIONYonkers
LOCATION
Michael Cohen
PERSONPersonal Income Tax Information Center
ORGANIZATION
FinCEN
ORGANIZATIONFiler
PERSONNY State
ORGANIZATION
Empire State
LOCATIONthe U.S. Treasury Financial Agent
ORGANIZATION