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EFTA01193775 | EFTA01193777 Record of Authorization to Electronically File FBARs Form 11zia Department of the Treasury Financial Crimes Enforcement Network (FinCEN) IALN .1 l (See instructions below for completion) \ vac 0 se 43 Do not send to FMCEN. Retain this form for your records. October 2013 Pert I I Persons who have an obligation to file a Report of Foreign Bank and Financial Account(s) 1. Owner last name or entity's legal name 2. Owner first name EPSTEIN 4. Spouse last name (if Jointly filing FEAR - see instructions below) 5. Spouse first name 3. Owner PA I. JEFFREY 6. Spouse M. I. (enter number of accounts) foreign bank and financial account(s) for the Uwe declare that 'Ave have provided information concerning 2 to the preparer listed in Part II that this information is to the best of my/our knowledge true, correct. filing year ending December 31, 2 013 and complete; that Uwe 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 1/we have provided; and that Uwe authorize the preparer listed in Part II to receive information from FInCEN. answer inquiries and resolve issues relating to this submission. lAve acknowledge that, notwithstanding this declaration, it is my/our legal responsibi ity. not that of the preparer listed in Part II, to timely file an FBAR if required by law to do so. 7 et signature (Authorized representatNe if entity) BDate 9 Owner or entity TIN NA t typo mar DD I Wye 12 Date 11. Spouse signature 10 TIN 14 ym 13 Spouse 11N a U EIN b 0 SSNIITIN C Foreign a EIN type b r c swop i YYrir SSWITIN Foreign Pait.01 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 CPA DAVID 19 Address 20 City 23 Country code 24 Preparers (item 15) employer's (Entity) name 17. Preparer 21 State 25. Employer EIN . 18. Preparer PTIN 22 ZIP/postal code 26. Preparers signature STIR, CPA' S LLC Instructions for completing the FBAR Signature Authorization Record This record may be completed by the individual or entity granting such authorization (Part I) OR the individual/entity authorized to perform such services. The completed record must be signed by the Individual(s)/entity granting the authorization (Part I) and the individual/entity that will file the FBAR. The Preparer/filing entity must be registered with FinCEN BSA E-File system. (See httpabsaefilingfincen trees gmernain.htne 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 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 Pan II in its entirety (do not use such terms as see above, or same as Aem number x ). Complete Part tl, items 15 through 18 with the preparer's Information. The address, items 19 through 23, is that of the preparer or the preparers employer If the preparer is an employee. Record the employer's information (if any) in items 24 and 25. tf the emperor 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 authonty. The person(s) listed In Part I. and the person listed in Part 11 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. BAA PDMb3OIL *mans Rev. 10.4 July 11, 2013 EFTA01193777
May 13, 2026 at 1:31 AM