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m 15) employer's (En ity) name DAVID WEISS CPA, PLLC 25. Employer EIN **_*** 26. Preparers ignature DAVID WEISS Instructions for completing the FBAR S gnature Authorization Record This record may be completed by the individual or entity granting such authorization (Part I) OR the individuaVentity authorize
above P"' Taxable refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here ► 7 8a 740. 9a 10 11 12 13 14 15b 16b 17 18 19
rs (item 15) employer's (En ity) name DAVID WEISS CPA, PLLC 25. Employer EIN 26. Preparers signature DAVID WEISS Instructions for completing the FBAR S gnature Authorization Record This record may be completed by the individual or entity granting such authorization (Part I) OR the individuaVentity authorize
through 35 Taxable refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ ► 7 8a 755. 9a 10 11 12 13 14 15b 16b 17 18 19 20b 21 22 1,645,828. ► 1,646,583. Adjusted Gross Income 23 24 25 26 2
5) employers (En ity) name DAVID WEISS CPA, PLLC 25. Employer EIN **-***2756 26. Preparers ignature DAVID WEISS Instructions for completing the FBAR S gnature Authorization Record This record may be completed by the individual or entity granting such authorization (Part I) OR the individuaVentity authorize
ets of state and local income taxes 10 1099-R if tax was withheld. 11 Alimony received 11 12 Business income or (loss). Attach Schedule C or C-EZ 12 13 Capital gain or (loss). Attach Schedule D U required. If not required, ohm* here 13 If you did not get a W-2, 14 Other gains or (los
Entities connected to both FBAR S gnature and C-EZ
Spouse
ORGANIZATION
U.S. Treasury
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATION
United States
LOCATIONSchedule SE
PERSON
FinCEN
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONFiler
PERSONERO Signature
ORGANIZATIONJurat/Disclosure
ORGANIZATIONForeign Bank
ORGANIZATIONBSA Efiling
ORGANIZATIONUtilities
ORGANIZATION
Joi Ito
PERSONConservation Reserve Program
ORGANIZATIONthe Foreign Bank and Financial Accounts Report
ORGANIZATIONPreparer
ORGANIZATIONConservation Reserve
ORGANIZATIONJohn O. Smith
PERSONthe New York State Tax Department
ORGANIZATION