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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
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 Education Fund 601 .00 60g 9/11 Memorial 60g .00 60h Vol
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
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 Education Fund 601 .00 60g 9/11 Memorial 60g .00 60h Volu
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,
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 Education Fund 601 .00 60g 9/11 Memorial 60g .00 60h Volu
Entities connected to both Spouse and 60e Olympic Fund

New York City
LOCATION
United States
LOCATION
Joi Ito
PERSON
New York
LOCATION
U.S. Treasury
ORGANIZATION
NEW YORK NY
LOCATIONUtilities
ORGANIZATIONERO Signature
ORGANIZATIONC-EZ
ORGANIZATIONPreparer
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATIONSchedule SE
PERSON
FinCEN
ORGANIZATIONMaria Farmer
PERSONFiler
PERSONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONBSA Efiling
ORGANIZATIONTHE NY TAX DEPT
ORGANIZATIONPersonal Income Tax Information Center
ORGANIZATION
Empire State
LOCATION