EFTA01077866.pdf

TAX RETURN FILING INSTRUCTIONS REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS - TAXPAYER FOR THE YEAR ENDING DECEMBER 31, 2013 Prepared for illigilii Prepared by RAICH ENDE MALTER & CO., LLP 1375 BROADWAY NEW YORK, NY 10018 Form must be filed on or before RETURN FORM 114A TO US ON OR BEFORE JUNE 30, 2014. Special Instructions THE TAXPAYER'S FORM 114 HAS BEEN PREPARED FOR ELECTRONIC FILI/ G. PLEASE SIGN, DATE, AND RETURN FORM 114A TO OUR OFFICE. WE WII L THEN TRANSMIT THE TAXPAYER'S FORM TO THE FINCEN. 30009T 10-M13 EFTA01077866  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. LEONDBL20130001 Part I I Persons who have an obligation to file a Report of Foreign Bank and Financial Accounts) 1. Owner last name or entity s legal name 2. Owner first name 3. Owner BLACK LEON D 4. Spouse last name (if jointly filing FBAR - see instructions below) 5. Spouse first name 6. Spouse s. I/we declare that I/we have provided information concerning 16 (en er number of accounts) foreign bank and financial account(s) for the tiling year ending December 31. 2 013 to the preparer listed in 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 I/we have provided; and that I/we authorize the preparer listed in Part II to receive information from FinCEN, answer inquiries and resolve issues relating to this submission. I/we 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 I I EIN type b II SSN/ITIN MM DD YYYY c C Foreign 11. Spouse signature 12. Date 13. Spouse TIN 14. TIN a I I EIN type b C SSN/ITIN MM DD YYYY c C Foreign Part III 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 M. 18. Preparer PTIN TURRIN THOMAS 19. Address 20. City 21. State 22 ZIP/postal code 1375 BROADWAY NEW YORK NY 10018 23. Country 24. Preparer's (item 15) employer's (Entity) name 25. Employer EIN 26. Preparer's signature code US ICH ENDS HALTER & 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 l) OR the individuaVentity authorized to perform such services. The completed record must be signed by the individual(s)/entity granting the authorization (Part I) and the individuaVeMity that will file the FBAR. The Preparer/filing entity must be registered with FinCEN BSA EFile system. (See http://bsaefiling.fncentreas.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 (FBAR). 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 FBAR 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 4. 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 prepare( 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 prepare( 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 person(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. N-01-13 Rev. 10.4 July 11, 2013 7 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077867  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 LEONDBL20130001 Effective January 1, 2014 Filing Name LEON D. BLACK 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 F8AR 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. Forgot to file b. I=1 Did not know that I had to file c. I=1 Thought account balance was below reporting threshold d. I=1 Did not know that my account qualified as foreign e. I=1 Account statement not received in time I=1 Account statement lost (Replacement requested) g Late receiving missing required account information h Unable to obtain joint spouse signature in time Unable to access 8SA Efiling system Other (please provide explanation below) 321151 08.13.13 1 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077868  FinCEN Form 114 REPORT OF FOREIGN BANK 1 This report is for calendar cieewerecii a the Treasoy O& no 1506-0009 AND FINANCIAL ACCOUNTS year ended 12/31 tRev. September 20131 Do NOT file with your Federal Tax Return 2013 Do not use previous editions of this form Ameded I Part I I Filer info matron LEONDBL20130001 2 Type of filer a LM Individual b El Partnership c Q Corporation d El Consolidated e Fiduciary or other • Enter type 3 U.S. Taxpayer Identification Number 3a TIN type 4 Foreign identification (Complete only if item 3 is not applicable) 5 Individual's date of birth MM/DD/YYYY SSN/ITIN a Type' El Passport C Foreign TIN El Other If filer has no U_S Identification El EIN number complete item 4 b Number c Country of Issue 6 Last name or organization name 7 First name 8 Middle initial 8a Suffix BLACK LEON D 9 Mailing address (number. street. and apt. or suite no.) 10 14 a) Does the filer have a financial interest in 25 or more financial accounts? Yes C Enter number of accounts Do not complete Part II or Part III, but maintain records of the information. No XI b) Does the filer have signature authority over but no financial interest in 25 or more financial accounts? Yes Enter number of accounts Comp. Part IV, items 34 through 43 for each person on whose behalf the filer has sign. authority. No IXI 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 1)1_1 Securities cLJ Other • Enter type below unknown 917,558. 17 Name of financial institution in which account is held BANK OF SCOTLAND 18 r other designation 9 Maifi address number. street. apt. or suite no.) of financial institution in which account is held gna re 44a Check here I I if this report is completed by a third party preparer and complete the third ,arty preparer section. 44 Filer signature 45 Filer title, if not reporting a personal account 46 Date (MWDp The meal wi be Sarawak, This dale willa=en the w FEAR eloc •nl 47 Preparer's last name 48 First name 50 Checker if 51a TIN type L.I PTIN URRIN THOMAS seltemployed SSN/ITIN Foreign Third Party 52 Contact phone no. 52a Ext. Irt.A 3 Firm's name 54a TIN type LXJ EIN Preparer 12-944-4433 ICH ENDE MALTER & El Foreign Use Only 55 Mailing address (number, street, apt. or suite no.) 56 City 57 State 56 ZIP/Postal Code 59 Country 375 BROADWAY NEW YORK NY 10018 US This form should e used to report a financial interest in, signature authority, or other authority over one or m re 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 he accounts did not exceed $10,000. See instructions for definitions. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Pursuant to the requirements of Pubic 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 USC 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 5600,000 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, M. Box 39, Vienna, VA 22183, Attn: Office of Regulatory Policy. 323141 10.30.13 Rev 5.7 • 6/3/2013 2 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077869  rPart II Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 1 of 3 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year IM Taxpayer Identification Number 2013 Foreign Identification Number Enter identification number here: BLACK 15 Maximum value of account during calendar year 15a Amount1133n 16 Type of account a IX' Bank b L1 Securities e LJ Other - Enter type below 6,050,010. 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 1 15 Maximum value of account during calendar year sa Amount Unknovm 18 Type of account a ti Bank b Securities c Other - Enter type below 947,856. ILI 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 20 15 Maximum value of account during calendar year 15a Anount Unknovm 16 Type of account a LXJ Bark b LJ Securities e U Other - Enter type below 964,177. O 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 20 16 Maximum value of account during calendar year 15a Amount Unknowt 16 Type of account a Bank b Securities c Other - Enter type below 17,619. 0 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 18 Account number or other desi nation 19 Mailin Address Number Stree Suite Number of financial institution in which account is held 20 16 Maximum value of account during calendar year the Arncunt Unknown 16 Type of account a Lx.l Bark b Securities c LJ Other - Enter type below 138,667. 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 20 16 Maximum value of account during calendar year isa Amount Unknarn 18 Type of account a Bank b LI Securities c LI Other - Enter type below 64,575. 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 18 Account number or other designation 119 Mailing Address (Number, Street Suite Number) of financial institution in which account is held 320015 09.24.13 3 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077870  rPart II Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 2 of 3 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year IM Taxpayer Identification Number 2013 0 Foreign Identification Number Enter identification number here: BLACK 15 Maximum value of account during calendar year sa ml unknown 16 Type of account a IX' Bank b LJ Securities e LJ Other - Enter type below 28,163. 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a Bank b Securities c Other - Enter type below 4,614. 17 Name of Financial Institution in which account is held LA CAIXA 20 15 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a Bark b LJ Securities e LJ Other - Enter type below 152,939. O 17 Name of Financial Institution in which account is held COMMERZBANK AG 18 Account number or other desi nation 19 Mailin Address Number. Street. Suite Number of financial institution in which account is held 20 16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a Bark b Securities c Other - Enter type below 874,673. 17 Name of Financial Institution in which account is held SOCIETE GENERALE 18 Account number or other desi nation in in which accoun held 15 Maximum value of account during calendar year sa nt Unknown 18 Type of account a tY Bank b Securities c Other - Enter type below 16,177. 0 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 16 Maximum value of account during calendar year 5a Amount Unknown, 18 Type of account a Bark b Securities c Other - Enter type below 44,086. 0 17 Name of Financial Institution in which account is held BANK OF TOKYO-MITSUBISHI UFJ LTD 18 Account number or other designation j19 Mailing Address (Number. Street Suite Number) of financial institution in which account is held 520015 oe.es.i 4 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077871  rPart II Continued - Information on Financial Account(s) Owned Separately FORM 114 Complete a Separate Block for Each Account Owned Separately Page Number 3 of 3 1 Filing for calendar 3-4 Check appropriate Identification Number 6 Last Name or Organization Name year IM Taxpayer Identification Number 2013 Foreign Identification Number Enter identification number here: BLACK 15 Maximum value of account during calendar year .15a Amount tin 16 Type of account a LXJ Bank b Li Securities e Li Other - Enter type below 44,483. O 17 Name of Financial Institution in which account is h Id BANK OF TOKYO-MITSUBISHI UFJ LTD 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 15 Maximum value of account during calendar year 5,a Amount Unknotem 16 Type of account a Bank b Securities e Other - Enter type below 84,796. 0 17 Name of Financial Institution in which account is held CREDIT SUISSE AG 20 16 Maximum value of account during calendar year isa Amount Unknown 16 Type of account a LX.I Bank b U Securities c LJ Other - Enter type below 1. 17 Name of Financial Institution in which account is held BANK OF TOKYO-MITSUBISHI UFJ, LTD 18 Account number or other deli' nation Mailin Address Number Stree Suite Number of financial institution in which account is held 16 Other -Enter type below 17 Name of Financial Institution in which account is held 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 [Lj 23 Country 15 Maximum value of account during calendar year lea Amount Unkn 16 Type of account a Li Bank b Securities c Li Other - Enter type below O 17 Name of Financial Institution in which account is held 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 15 Maximum value of account during calendar year 1$8 Amount Unknown 16 Type of account a Bank b Securities c L.J Other - Enter type below O 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 320015 09.24.13 5 16430626 133415 T-1009 2013.04000 BLACK, LEON T-10093 EFTA01077872