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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
f activities at each loca ion (manufacturing, sales office. executive , and number of employees, their " ages salaries and duties at each location. Complete Address Rent Nature of Activities Empioyees Wages, Salaries, Etc. Duties I I I I Total Illl• Part 2 List location of each place of business UU
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
e of activities at each loca ion (manufacturing, sales office. executive and number of employees, their wages salaries and duties at each location. Complete Address Rent Nature of Activities No ry Frnoioyeas Wages, Salaries, Etc. Duties I I I I Total Part 2 List location of each place of business UU I
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,
e of activities at each loca ion (manufacturing, sales office, executive and number of employees, their wages salaries and duties at each location. Complete Address Rent Nature of Activities No Emoroyees Wages, Salaries, Etc. Duties I I I I Total I, Part 2 List location of each place of business UU
Entities connected to both Spouse and Complete Address

Joi Ito
PERSON
New York
LOCATION
United States
LOCATION
New York City
LOCATION
NEW YORK NY
LOCATION
U.S. Treasury
ORGANIZATIONUtilities
ORGANIZATIONMaria Farmer
PERSONERO Signature
ORGANIZATIONC-EZ
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATIONPreparer
ORGANIZATION
FinCEN
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONFiler
PERSONSchedule SE
PERSONFBAR S gnature
ORGANIZATIONthe Foreign Bank and Financial Accounts Report
ORGANIZATIONForeign Bank
ORGANIZATIONBSA Efiling
ORGANIZATION