Do you have financial interest in 25 or more financial accounts? * Yes No Do you have signatory authority over but no financial interest in 25 or more financial accounts? * Yes No Information on Financial Accounts Owned Separately Type of Account Bank Securities Other Maximum account value * (document the highest balance on any given day during the year using the currency the account is denominated) do not convert to USD $ Foreign Currency (currency the account balance is denominated) Account Number * Financial Institution Name * Address of Financial Institution * Address 1 Address 2 City State/Province Zip/Postal Code Country Information on Accounts Jointly Owned (ex. jointly owned by you and your spouse) Type of Account * Bank Securities Other Maximum Account Value * (document the highest balance on any given day during the year using the currency the account is denominated) do not convert to USD $ Foreign Currency * (currency the account balance is denominated) Account Number Financial Institution Name Address of Financial Institution Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
