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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
ealth Education 60i .00 60) Veterans Remembrance 60) .00 60k Homeless Veterans 60k .00 601 Mental Illness AntiStigrna Fund 601 .00 60m Women's Cancers Education and Prevention Fund 60m .00 60n Autism Fund 60n .00 60o Veterans' Homes 60o .00 60 Total voluntary contributions (add tines 60a through 60o) 61 Total New Y
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
ealth Education 60i .00 60) Veterans Remembrance 60) .00 60k Homeless Veterans 60k .00 601 Mental Illness Anti-Stigma Fund 601 .00 60m Women's Cancers Education and Prevention Fund 60m .00 60n Autism Fund 60n .00 60o Veterans' Homes 60o .00 60 Total voluntary contributions (add tines 60a through 60o) 61 Total New Y
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,
ealth Education 60i .00 60) Veterans Remembrance 60) .00 60k Homeless Veterans 60k .00 60I Mental Illness Anti-Stigma Fund 601 .00 60m Women's Cancers Education and Prevention Fund 60m .00 60n Autism Fund 60n .00 60o Veterans' Homes 60o 00 60 Total voluntary contributions (add fines 60a through 60o) 61 Total Now Yo
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
en Hearth Education 60i 00 60) Veterans Remembrance 60) 00 60k Homeless Veterans 60k 00 601 Mental Illness AntiStigrna Fund 601 00 60m Women's Cancers Education and Prevention Fund 60m 00 60 Total voluntary contributions (add fines 60a through 60m) too 61 Total New York State, New York City, Yonkers, and sales or use taxe
Entities connected to both Spouse and Women's Cancers Education and Prevention Fund

New York City
LOCATION
New York
LOCATION
United States
LOCATION
Joi Ito
PERSON
U.S. Treasury
ORGANIZATION
NEW YORK NY
LOCATIONUtilities
ORGANIZATIONC-EZ
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONNY State
ORGANIZATION
New York State
LOCATION
Empire State
LOCATIONthe U.S. Treasury Financial Agent
ORGANIZATIONthe New York State Tax Department
ORGANIZATIONNY City
LOCATIONMaria Farmer
PERSONFiler
PERSONFirst Installment
ORGANIZATIONYonkers
LOCATION
FinCEN
ORGANIZATION