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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
9 blank 4 , Voluntary contributions] (see page 27) 60a Return a Gift to Wildlife 60a .00 60b Missing/Exploited Children Fund 60b .00 60c Breast Cancer Research Fund 60c .00 60d Alzheimer's Fund 60d .00 60e Olympic Fund ($2 or $4; see page 27) 60e .00 601 Prostate and Testicular Cancer Research and Ed
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
9 blank ) 04'pr Voluntary contributions (see page 27) 60a Return a Gift to Wildlife 60a .00 60b Missing/Exploited Children Fund 60b .00 60c Breast Cancer Research Fund 60c .00 60d Alzheimer's Fund 60d .00 60e Olympic Fund ($2 a $4; see page 27) 60e .00 601 Prostate and Testicular Cancer Research and Edu
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,
9 blank ) 04'pr Voluntary contributions (see page 27) 60a Return a Gift to Wildlife 60a .00 60b Missing/Exploited Children Fund 60b .00 60c Breast Cancer Research Fund 60c .00 60d Alzheimer's Fund 60d .00 60e Olympic Fund (52 a $4; see page 27) 60e .00 601 Prostate and Testicular Cancer Research and Edu
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
do not leave fine 59 ) 59 Voluntary contributions 60a Return a Gift to Wildlife 60a 00 60b Misstig/Exploited Children Fund 60b 00 60c Breast Cancer Research Fund 60c 00 60d Alzheimer's Fund 60d 00 60a Olympic Fund (52 or 34; see page 27) 60e 00 601 Prostate and Testicular Cancer Research and Educa
Entities connected to both Spouse and Breast Cancer Research Fund

New York City
LOCATION
United States
LOCATION
Joi Ito
PERSON
New York
LOCATION
U.S. Treasury
ORGANIZATION
NEW YORK NY
LOCATIONUtilities
ORGANIZATIONNY State
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATION
New York State
LOCATIONFirst Installment
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATION
Empire State
LOCATIONYonkers
LOCATION
FinCEN
ORGANIZATIONTHE NY TAX DEPT
ORGANIZATIONERO Signature
ORGANIZATIONSchedule SE
PERSONC-EZ
ORGANIZATIONthe New York State Tax Department
ORGANIZATION