Department of the Treasury–Internal Revenue Service 
Form 14454                                                                                                                                            OMB Number 
(July 2014)           Attachment to Offshore Voluntary Disclosure Letter                                                                              1545-2241
                                        (One attachment is required for each financial institution)
Please ensure all pages of Form 14454 include your name, the last four digits of your taxpayer identification number, the name of the 
foreign financial institution, and the account number for which you are responding. 
For each foreign financial account of which you have control or are a beneficial owner, provide the following information.
Taxpayer Name                                                                                 Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name                                                        1b. Account Number

2.   Country, including address, where the account was established (If different, country,    3. Date the account was opened DO NOT LEAVE BLANK 
including address, where account is currently located)                                        (if unsure, please estimate)

                                                                                              4a. Is the account still open?
                                                                                              Yes                No
                                                                                              4b. If “No,” when was the account closed

5.   Identify the individual(s), affiliates and/or organization(s) (e.g., banks, independent financial advisors, trust or corporate service providers) who advised or 
assisted you in opening and using/maintaining the account. Include contact information for individual(s), affiliates, and/or organization(s)

6a. Explain all communications you had regarding the opening and use/maintenance of the account. Identify the individuals (whether affiliated with the 
foreign financial institution or independent from the financial institution), dates, and form (e.g., face-to-face meeting, phone, email, fax, etc.) of the communication.

6b. Any meetings, phone calls, faxes, emails, or any other communications from these individuals to you in the U.S.?
Taxpayer              Yes               No
Spouse                Yes               No
Related entities      Yes               No
If “Yes,” where
6c. Are any of the individuals a business person (advisor), accountant, attorney, or return preparer in the U.S.?
Taxpayer              Yes               No
Spouse                Yes               No
Related entities      Yes               No
If “Yes,” identify which organization(s)
7.   With respect to communications you had about your foreign financial account, provide the following:
7a. Did a representative of the foreign financial institution or advisor visit you in the United States regarding the offshore account?
Taxpayer              Yes               No
Spouse                Yes               No
Related entities      Yes               No
7b. Did a representative of the foreign financial institution or advisor suggest to you the use of offshore accounts, offshore investments, offshore 
entities, or particular foreign countries as a way of avoiding the disclosure of your ownership of the account or avoiding taxes?
Taxpayer              Yes               No
Spouse                Yes               No
Related entities      Yes               No
If “Yes,” provide the dates and locations for all meetings

Catalog Number 61606G                                                       www.irs.gov                                     Form 14454 (Rev. 7-2014) 

                                                                                                                                                         Page 2
Taxpayer Name                                                           Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name                                  1b. Account Number

7c. Did a representative of the foreign financial institution or advisor suggest to you the use of practices, such as holding mail at the institution, using 
prepaid phone cards, using credit or debit cards, communicating via fax or email, bank storage of account documentation, or conducting face-to-
face-meetings, to avoid the disclosure of your ownership of the account?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
7d. Did a representative of the foreign financial institution, one of its U.S. subsidiaries, or advisor provide services in the U.S. related to offshore 
accounts (e.g., facilitating opening accounts, reviewing account activity, forwarding account statements, providing investment and/or tax advice, 
etc.)?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
7e. Did a representative of the foreign financial institution or advisor suggest you meet in a jurisdiction outside the U.S. and other than where the 
institution is located?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
If “Yes,” provide the dates and locations for all meetings

7f.  Did a representative of the foreign financial institution or advisor suggest you either not file a voluntary disclosure with the IRS or repatriate the 
foreign funds into the U.S.?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
7g. Did an advisor or other person attempt to influence you to move funds from one foreign financial institution to another or from one foreign country 
to another?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
8a. What documentation was received by or shown to you regarding opening and maintenance of the account (e.g., account statements, account opening 
documents, etc.)?

8b. Who showed you the documentation and when?

8c. Did you retain any of the documents?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No
If “Yes,” identify the documents retained
If “No,” explain why you did not retain them
9.   Were you able to make deposits to or withdrawals from your account through the use of a U.S. domestic branch office of the foreign financial 
institution?
Taxpayer                    Yes             No
Spouse                      Yes             No
Related entities            Yes             No

Catalog Number 61606G                                     www.irs.gov                                   Form 14454 (Rev. 7-2014) 

                                                                                                                                                       Page 3
Taxpayer Name                                                                                     Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name                                                            1b. Account Number

10a. Did you or someone on your behalf make deposits (beyond the initial opening deposit) to the account?
Taxpayer                        Yes     No
Spouse                          Yes     No
Related entities                Yes     No
Entity name                                                                                              Telephone number
Address
If “Yes,” respond to the following:
10b. How did you make a deposit (e.g., in person, online, phone, ATM, use of third-party, etc.)?
10c. What form were the deposits in (e.g., cash, check, wire, traveler’s check, etc.)?
10d. What documents did you receive when a deposit was made (e.g., receipt, credit memo, etc.)?
10e. If funds were transferred from other financial institutions, provide the following information:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
11a. Did you or someone on your behalf withdraw money from the account?
Taxpayer                        Yes     No
Spouse                          Yes     No
Related entities                Yes     No
Entity name                                                                                              Telephone number
Address
If “Yes,” respond to the following:
11b. How were the funds withdrawn (e.g., in person, online, phone, ATM, use of third-party, etc.)?
11c. What form were the withdrawals in (e.g., cash, check, wire, debit, etc.)?
11d. What documents were received when a withdrawal was made (e.g., receipt, debit memo, etc.)?
11e. If funds were transferred from other financial institutions, provide the following information:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
12a. Did you move any funds into the United States during the life of the account?
Taxpayer                        Yes     No
Spouse                          Yes     No
Related entities                Yes     No
Entity name                                                                                              Telephone number
Address
If “Yes,” respond to the following:
12b. In what form did you move the funds (e.g., cash, check, wire, bank checks, etc.)?
12c. Did you engage in any transactions or series of transactions or use any third parties or other methods or schemes to move the money back into the 
United States (e.g. loans, business invoices, other entities, third parties, etc.)?  If yes, explain and identify all individuals and entities involved

Catalog Number 61606G                                       www.irs.gov                                                  Form 14454 (Rev. 7-2014) 

                                                                                                                                                    Page 4
Taxpayer Name                                                                                     Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name                                                            1b. Account Number

12d. Provide the following information about the Financial Institution:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
13a. Did you move any funds to a country outside the jurisdiction of the country where the account was held?
Taxpayer                              Yes        No
Spouse                                Yes        No
Related entities                      Yes        No
Entity name                                                                                                   Telephone number
Address
13b. If funds were transferred to other financial institutions, provide the following information:
Financial Institution(s)/Location(s)
Name on account(s)
Amount of transfer(s)
Date(s) of transfer
14a. Are there other individuals affiliated with the account(s)?
Taxpayer                              Yes        No
Spouse                                Yes        No
14b. If “Yes,” identify each person affiliated with each account, including the nature of their relationship to the account (e.g., owner, beneficial owner, power of 
attorney, signatory authority, etc.)

15a. Is an entity affiliated with the account(s)?
Taxpayer                              Yes        No
Spouse                                Yes        No
If “Yes,” respond to the following for each entity:
15b. Identify the entity, including the nature of its relationship to the account (e.g., nominee owner, beneficial owner, power of attorney, parent entity of corporate 
account holder, etc.)

15c. Identify the entity’s formal structure (e.g., corporation, foundation, trust, etc.)
15d. Identify the country where the entity was organized
15e. Identify the individual(s) and/or organization(s) (e.g., the foreign bank, an outside professional, etc.) who suggested forming the entity and who formed the 
entity

15f.  Identify the individual(s) or organization(s) that managed the entity
15g. Is the entity still in existence?
Taxpayer                              Yes        No
Spouse                                Yes        No

Catalog Number 61606G                                           www.irs.gov                                                   Form 14454 (Rev. 7-2014) 

                                                                                                                                                    Page 5
Taxpayer Name                                            Last Four Digits of Taxpayer Identification Number

1a. Foreign Financial Institution Name                   1b. Account Number

15h. Was a business person (advisor), accountant, attorney, or return preparer in the U.S. involved in setting up the entity or in advising its use?
Taxpayer                   Yes         No
Spouse                     Yes         No
If “Yes,” identify the individual(s)

15i.  Was a U.S. bank, brokerage firm or other financial services company involved in setting up the entity or in advising its use?
Taxpayer                   Yes         No
Spouse                     Yes         No
If “Yes,” identify the bank, firm, or company

                                       Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this foreign account or asset statement to carry out the Internal Revenue laws of the United States. Our authority to ask for 
information is sections 6001, 6109, 7801, 7803 and the regulations thereunder. This information will be used to determine and collect the correct amount 
of tax under the terms of the offshore voluntary disclosure program. You are not required to apply for participation in the offshore voluntary disclosure 
program. If you choose to apply, however, you are required to provide all the information requested on the foreign account or asset statement.  
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document 
displays a valid OMB control number. Books or records relating to a document or its instructions must be retained as long as their contents may become 
material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. 
Section 6103, however, allows or requires the Internal Revenue Service to disclose or give this information to others as described in the Internal 
Revenue Code. For example, we may disclose this information to the Department of Justice to enforce the tax laws, both civil and criminal, and to cities, 
states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also disclose this information to other 
countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence 
agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application. Providing false information may 
subject you to penalties.  
The time needed to complete and submit the foreign account or asset statement will vary depending on individual circumstances. The estimated 
average time is: 2 hour. 
 If you have comments concerning the accuracy of this time estimate or suggestions for making the foreign account or asset statement simpler, we 
would be happy to hear from you. Comments should be sent to the Internal Revenue Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:
SP, Washington, DC 20224.
Catalog Number 61606G                        www.irs.gov                             Form 14454 (Rev. 7-2014)