EFTA00619455.pdf

TAX RETURN FILING INSTRUCTIONS REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS DECEMBER 31, 2014 Prepared for APO2 DECLARATION (C/O ELYSIUM MGT., LLC) Prepared by RAICH ENDE MALTER & CO., LLP Form must be filed on JUNE 30, 2015 or before Special FORM 114 HAS BEEN PREPARED FOR ELECTRONIC FILING. PLEASE Instructions SIGN, DATE, AND RETURN FORM 114A TO OUR OFFICE. WE WILL THEN TRANSMIT YOUR REPORT TO THE FINCEN. 420397 0:3114 EFTA00619455  FINANCIAL CRIMES ENFORCEMENT NETWORK BSA E-Filing - Report of Version Number: 1.1 Foreign Bank and Financial FinCEN Form 114 Accounts (FBAR) OMB Control Number: 1506-0009 Effective January 1, 2014 Filing Name APO2 DECLARATION Submission Type NEW PIN NOT REQUIRED Check here if this report is submitted by an authorized third party, and complete the 3rd party preparer section on page one of the report. The E-file system will auto complete item 46. NOTE: The FBAR must be received by the Department of the Treasury on or before June 30th of the year immediately following the calendar year being reported. The June 30th filing date may not be extended. This report filed late for the following reason (Check only one): a 0 Forgot to file b O Did not know that I had to file c O Thought account balance was below reporting threshold d O Did not know that my account qualified as foreign e Account statement not received in time Account statement lost (Replacement requested) g O Late receiving missing required account information h O Unable to obtain joint spouse signature in time O Unable to access BSA Efiling system z O Other (please provide explanation below) 423151 05.01.14 EFTA00619456  Form 114a Record of Authorization to Department of the Treasury Financial Crimes Enforcement Electronically File FBARs Network (FinCEN) (See instructions below for completion) October 2013 Do not send to FinCEN. Retain this form for your records. Part I I Persons who have an obligation to file a Report of Foreign Bank and Financial Accounts) I. Owner last name or entity's legal name 2. Owner first name 3. Owner APO2 DECLARATION C/O ELYSIUM MANAGEMENT LLC 4. Spouse last name (if jointly filing FBAR • see instructions below) 5. Spouse first name 6. Spouse Vwe declare that Vwe have provided information concerning 1 (enter number of accounts) foreign bank and financial account(s) for the filing year ending December 31. 2 014 to the preparer listed ii Part II: that this information is to the best of my/our knowledge true, correct. and complete: that I/we authorize the preparer listed in Part II to complete and submit to the Financial Crimes Enforcement Network (FinCEN) a Report of Foreign Bank and Financial Accounts (FBAR) based on the information that Vwe have provided: and that Vwe authorize the preparer listed in Part II to receive information from FinCEN. answer inquiries and resolve issues relating to this submission. Vwe acknowledge that. notwithstanding this declaration, it is my/our legal responsibility, not that of the preparer listed in Part II, to timely file an FBAR if required by law to do so. 7. Owner signature (Authorized representative if entity) 8. Date 9. Owner or entity TIN 10. TIN a Uri EIN type b 0 SSWITIN MM DD YYYY c 0 Foreign 11. Spouse signature 12. Date 13. Spouse TIN 14. TIN a I__I EIN type b 0 SSN/ITIN MM DD YYYY c 0 Foreign Part II I Individual or Entity Authorized to File FBAR on behalf of Persons who have an obligation to file. 15. Preparer last name 16. Preparer first name 17. Preparer 18. Preparer PTIN TURRIN THOMAS 19. Address 20. City 21. State 22. ZIP/postal code p 23. Country 24. Preparer's (item 15) employer's (En ity) name 25. Employer EIN 26. Preparer's ignature code US RAICH ENDE MALTER & CO., LLP 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 authorized to perform such services. The completed record must be signed by the individual(syentity grant ng the authorization (Part I) and the individuaVentity that will file the FBAR. The Preparer/filing entity must be registered with FinCEN BSA EFile system. (See http://bsaefiling.fincen.treas.gov/main.html for registration). Read and complete the account owner statement in Part I. To authorize a third party to file the Foreign Bank and Financial Accounts Report (FEAR), the account owner should complete Part I. items 1 through 3 (as required), sign and date the document in Part I. items 7/8 and complete items 9 and 10. Accounts Jointly Owned by Spouses (see exceptions in the FBAR instructions) If the account owner is filing an FEAR jointly with his/her spouse. the spouse must also complete Part I. items 4 through 6. The spouse must also sign and date the report in items 11/12. and complete items 13 and 14. A third party preparer may be one of the spouses of the jointly owned foreign account. In this case, both spouses must complete Part I of form 114a in its entirety. The third party preparer (spouse) that will file the FBAR on behalf of both spouses will complete Part II in its entirety (do not use such terms as see above, or same as item number X). Complete Part II. items 15 through 18 with the preparer's information. The address, items 19 through 23. is that of the preparer or the preparer's employer if the preparer is an employee. Record the employer's information (if any) in items 24 and 25. If the preparer does not have a PTIN. leave item 18 blank. The third party preparer must sign in item 26 of Part II indicating that the FBAR will be filed as directed by the authorizing authority. The person(s) listed in Part I. and the person listed in Part II as authorized to file on behalf of the persca(s) listed in Part I, should retain copies of this record of authorization and the filing itself. both for a period of 5 years. See 31 CFR 1010.430(d). DO NOT SEND THIS RECORD TO FinCEN UNLESS REQUESTED TO DO SO. 054)1.14 Rev. 10.4 July 11. 2013 EFTA00619457  FinCEN Form 114 REPORT OF FOREIGN BANK 1 This report is for calendar Deportment of Its Miaow OMB no. MO6-0009 AND FINANCIAL ACCOUNTS year ended 12/31 eev. Soptomtor 2013) Do NOT tile with your Federal Tax Return 2014 Do not use previous editions of this form nAme I Part I I lifer information 2 Type of filer a 0 Individual b Partnership c 0 Corporation d 0 Consolidated e Fiduciary or other • Enter type 3 U.S. Taxpayer Identification Num 3a TIN type 4 Foreign Identification (Complete only if item 3 is not applicable) 5 Individuals date of birth MWDDNYYY SSNATIN a Type: 0 Passport IMI Foreign TIN 0 Other If filer has no U S Identification al BN number complete item 4 b Number c Country of Issue 6 Last name or organization name 7First name 8 Middle initial 8a Suffix APO2 DECLARATION C/O ELYSIUM MANAGEMENT LLC 9 Mailing address (number. street. and apt. or suite no.) 14 a) Does the filer have a financial interest in 25 or more financial accounts? Yes 0 Enter number of accounts Do not complete Part II or Part III, but maintain records of the Information. No b) Does the filer have signature authority over but no financial interest in 25 or more financial accounts? Yes 0 Enter number of accounts Comp. Pan IV, items 34 through 43 for each person on whose behalf the filer has sign. authority. No I Part III Information on financial account(s) owned separately 15 Maximum value of account during calendar year 15a Amount 16 Type of account aLXJ Bank bLJ Securities cLJ Other • Enter type below unknown 2,403,630. 17 Name of financial institution in which account is held BANK OF SCOTLAND 18 Account number or other designation 19 Mailing address (number, street. apt. or suite no.) of financial institution in which account is held 00152847 THE MOUND 20 City 21 State. if known 22 Foreign postal code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM I44 Filer signature 144a Check here LXJ if his report is completed b a third party preparer and complete the third party preparer section. signature 45 Filer title. if not reporting a personal account If 46 Date(MM/D Ito report Do &entrance/1y Mks data willpfurona illvi n tno Vaned *hen Mad FBAil Is oknaronlasnanod 47 Preparer's Last name 48 First name 49 MI 50 Checks Id 51 TIN 51a TIN type PTIN TURRIN THOMAS self-employed SSWMN 0 Foreign Third Party 52 Contact hone no. 52a Ext. 53 Firm's name 54 Firms TIN 54a TIN type LXJ EIN Preparer RAICH ENDE MALTER & 0 Foreign Use Only 55 Mailing address (number. street, apt. or suite no. 56 Cit 5.tate 58 ZIP octal Code 59 Country US This form should be used to report a financial interest in, signature authority, or other authority over one or more financial accounts in foreign countries, as required by the Department of the Treasury Regulations 31 CFR 1010.350. No report is required if the aggregate value of the accounts did not exceed $10,000. See inst uctions for definitions. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on FinCEN Form 114 in accordance with 5 USG 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301; 31 CFR 1010.350. The principal purpose for collecting the information is to assure maintenance of reports where such reports or records have a high degree of usefulness in criminal, tax, or regulatory investigations or proceedings. The information collected may be provided to those officers and employees of any constituent unit of the Department of the Treasury who have a need for the records in the performance of their duties. The records may be referred to any other department or agency of the United States upon the request of the head of such department or agency for use in a criminal, tax, or regulatory investigation or proceeding. The information collected may also be provided to appropriate state, local, and foreign law enforcement and regulatory personnel in the performance of their official duties. Disclosure of this information is mandatory. Civil and criminal penalties, including in certain circumstances a fine of not more than $500,000 and imprisonment of not more than five years, are provided for failure to file a report, for failure to supply information, and for filing a false or fraudulent report. Disclosure of the Social Security number is mandatory. The authority to collect is 31 CFR 1010.350. The Social Security number will be used as a means to identify the individual who files the report. The estimated average burden associated with this collection of information is 60 minutes per respondent or record keeper, depending on individual circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing the burden should be directed to the Financial Crimes Enforcement Network, • Box 39, Vienna, VA 22183, Attn: Office of Regulatory Policy. 423141 05-01.14 Rev 5.7 . 6/3/2013 EFTA00619458 Part III Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 2 of 4 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year Taxpayer Identification Number 2014 Foreign Identification Number APO2 DECLARATION number here: C/O ELYSIUM MANAGEMENT LLC 15 Maximum value of account during calendar year 15a Amo“ni Unknown 16 Type of account a I XI Bank b I I Securities e I I Other - Enter type below 1,983,043. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 'tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 15 Maximum value of account during calendar year 15a AfT04.111 Unknown 16 Type of account a LXJ Bank b LI Securities e I I Other - Enter type below 1,130,145. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 'tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 15 Maximum value of account during calendar year 15a Af1104.111 Unknown 16 Type of account a LXJ Bank b LI Securities e I I Other - Enter type below 688,824. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 'tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 15 Maximum value of account during calendar year 15a Af1104.111 Unknown 16 Type of account a LXJ Bank b LI Securities e I I Other - Enter type below 92,325. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 'tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 15 Maximum value of account during calendar year 15a Af1104.111 Unknown 16 Type of account a LXJ Bank b LI Securities e I I Other - Enter type below 177,194. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 'tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 15 Maximum value of account during calendar year 15a Af1104.111 Unknown 16 Type of account a LXJ Bank b LI Securities e I I Other - Enter type below 16,362. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 19 tailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 420a15 05.0111 EFTA00619459 Part II Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 3 of 4 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year W Taxpayer Identification Number 2014 Foreign Identification Number APO2 DECLARATION lion number here: C/O ELYSIUM MANAGEMENT LLC 16 Maximum value of account during calendar year isa Amount unknown 16 Type of account a Bank b Securities c LJ Other - Enter type below 10,403. 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 20 City 21 State, if known 22 ZIP/Postal Code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM 16 Maximum value of account during calendar year 15a Amount Unknown 16 Type of account a LXJ Bank b LJ Securities c LJ Other - Enter type below 2,794. 17 Name of Financial Institution in which account is h Id LA CAIXA 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held DIAGONAL-CARIES III, AV DIAGONAL 621-629 20 City 21 State, if known 22 ZIP/Postal Code, if known 23 County BARCELONA 08028 SPAIN 16 Maximum value of account during calendar year isa Anoint Unknown 16 Type of account a Bank b Securities c Other - Enter type below 90,296. 17 Name of Financial Institution in which account is held COMMERZBANK AG 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 16 KAISERSTRASSE 20 City 21 State, if known 22 ZIP/Postal Code, if known 23 Country FRANKFURT AMMAIN GERMANY 16 Maximum value of account during calendar year 1sa Anoint Unknown 6 Type of account a Bank b Securities C Other - Enter type below 209,317. 17 Name of Financial Institution in which account is held SOCIETE GENERALE 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held BERCY ENTR 10 AVENUE LEDRU ROLLIN 20 City 21 State, if known 22 ZIP/Postal Code, it known 23 County PARIS 75012 FRANCE 16 Maximum value of account during calendar year isa Anoint Unknown 16 Type of account a Bank b Securities c Other - Enter type below 16,508. 17 Name of Financial Institution in which account is held COMMONWEALTH BANK OF AUSTRALIA 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 48 MARTIN PL 20 City 21 State, if known 22 ZIP/Postal Code, if known 23 County SYDNEY NSW2000 AUSTRALIA 16 Maximum value of account during calendar year 1sa Arnow Unknown 6 Type of account a Bank b Securities C Other - Enter type below 30,555. 17 Name of Financial Institution in which accoun is held BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City 21 State, if known 22 ZIP/Postal Code, if known 23 County TOKYO 1710021 JAPAN 420:115 05-01-14 EFTA00619460 Part III Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 4 of 4 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year al Taxpayer Identification Number 2014 0 Foreign Identification Number APO2 DECLARATION • " lion number here: C/O ELYSIUM MANAGEMENT LLC 15 Maximum value of account during calendar year 15a Arnow Unknown 16 Type of account a I X I Bank b I I Securities c I I Other - Enter type below 1. 17 Name of Financial Institution in which account is h Id BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country TOKYO 1710021 JAPAN 15 Maximum value of account during calendar year 15a AcTOull lleikesOvol 16 Type of account a I X I Bank b I Securities e LJ Other -Enter type below 24,904. 17 Name of Financial Institution in which account is h Id BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City 21 State. if known 22 ZIP,Postal Code, if known 23 Country TOKYO 1710021 JAPAN 15 Maximum value of account during calendar year 15a AcTOull lleikes0vl 16 Type of account a I X I Bank b I Securities eLJ Other -Enter type below 69,052. 17 Name of Financial Institution in which account is h Id CREDIT SUISSE AG 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held POSTFACH 357, 20 City 21 State. if known 22 ZIP/Postal Code, if known 23 Country ZUG 6301 SWITZERLAND 15 Maximum value of account during calendar year 15a AcTOull Ifilkes0w0 16 Type of account a LJ Bank b LI Securities c LI Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street. Suite Number) of financial institution in which account is held L 23j Country 20 City 21 State. if known 22 ZIP/Postal Code, if known 15 Maximum value of account during calendar year 15a AcTOull IfilkesOwA 16 Type of account a LJ Bank b I Securities c LJ Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street. Suite Number) of financial institution in which account is held L 23j Country 20 City 21 State. if known 22 ZIP/Postal Code, if known 15 Maximum value of account during calendar year 15a AcTOull IfilkesOwA 16 Type of account a LJ Bank b I Securities c LJ Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street. Suite Number) of financial institution in which account is held 20 City 21 State. if known 22 ZIP/Postal Code, if known 23 Country 470015 05-01.14 EFTA00619461