Washington, D.C. 20530 US. Department of Justice Request for Financial Information Under the Right to Financial Privacy Act (RFPA) (Authorization, Purchase Order and Receiving Report) This form shall be used when requesting financial records of individuals and partnerships of five or fewer individuals under die RFPA. I Tracking Number j2 Date Order Prepared: 4 Name and Address of Financial Institution: 5 Deliver Records To: Section A - Authorization and Purchase Order Funding Certification & Authorization: 3 USAO Number: A. Budget Official Signature Funding Available Date B. 54-8113 N/A Apprining Official Signature Date Send Completed USA-21 I Form & Invoice To: 6 Return Date: V.S. Attorney's Office • SDNY Budget 1 Fiscal Unit 86 Clambers Street. led Floor New York. NY 10007 7 Remarks: Do not proceed with compliance if the total cost will exceed $ 500.00 without prior approval. To obtain approval. call the requestor listed in Item 8. If invoicing for these services is expected to exceed 120 days. please notify the United States Attorneys Office immediately to ensure funds remain available for payment. Please see the attached Important Notice for additional information on invoicing and other requirements for reimbursement. 8 Name of attestor AUSA Telephone Number Section B - Financial Institution Invoice 10 Date of request: No Payment Shall Bc Made Unless Expenses Arc Itemized Below Or Set Forth On Your Attached Invoice. IIA Invoice Number 11B Tax ID Number: I IC Service(s)/Records Provided: A. Searching and processing costs (clerical or technical personnel) B. Searching and processing costs (management/supervisory personnel) C. Searching and processing costs (computer support specialist) D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if the information is stored electronically. unless the US Attorney's Office requests paper. E. Reproduction Costs (Paper Copies of Microfiche: provide justification) F. Reproduction Costs (Duplicate Microfiche: provide justification) G. Storage Media Cost (e.g.. Compact Disc. DVD, etc.. at Actual Cost) H. Transportation Costs (Direct Costs Only) In Item 412. I certify that the services invoiced above were not performed relative to any corporate accounts and pertain only to accounts of individuals and partnerships of five or fewer individuals. 12 Signature of Financial Institution Official: Quantity Unit Price Cost Per $22.00 430.00 430.00 40.25 40.25 S0.50 Hour Hour Hour Page Frame Microfiche Amount Section C - Receiving Report 14 I certify that the articles and services listed were received: I3 Date Signed: 15 Date Received: Total Amount Claimed By Financial Institution I8 Right to Financial Privacy Act - Public Law 95-630 (12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only) SECTION r , 3404  3405  3406  3407  3408  3413 n 3414 22 Remarks: Customer Authorization Administrative Subpoena or Summons Search Warrant Judicial Subpoena Fomuil Written Request Grand Jury Subpoena Special Procedures OBJECT CLASS 2545 2545 2545 2545 2545 2545 2545 16 Disallowance (See Attached) 17 Net to Financial Institution I9 Signature of Approving Official: 20 Funding Source Accounting Code: Program I 21 Other Accounting/Fund Information: Program Code: NIA Project Code: NIA YREGDOC: 54-8113 Call Number (if applicable): OBL Month (TRAM): Tax ID Number. To the of my knowledge. the financial records received. for which we are being billed. are those of an individual or partnership of five or fewer Signature of United States Attorneys Office Repiesenkitive Date FORM USA -21I FEB. 2014 EFTA00027224