Form FinCEN Form 114 FinCEN Form 114 Report of Foreign Bank and Financial Accounts (FBAR)

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Version Number: 1.1

BSA E-Filing - Report of
Foreign Bank and Financial
Accounts (FBAR)

FinCEN Form 114
OMB Control Number: 1506-0009
Effective January 1, 2014

Filing Name

Submission Type

New or Amendment

Sign with PIN
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.

Forgot to file

b.

Did not know that I had to file

c.

Thought account balance was below reporting threshold

d.

Did not know that my account qualified as foreign

e.

Account statement not received in time

f.

Account statement lost (Replacement requested)

g.

Late receiving missing required account information

h.

Unable to obtain joint spouse signature in time

i.

Unable to access BSA E-filing system

z.

Other (please provide explanation below)

REPORT OF FOREIGN BANK
AND FINANCIAL ACCOUNTS

FinCEN Form 114
Department of the Treasury
OMB no. 1506-0009

2

Filer information

Individual

b

Partnership c

Corporation d

U.S. Taxpayer Identification Number 3a TIN type
If filer has no U.S. Identification
number complete item 4

SSN/ITIN
EIN

4

Fiduciary or other - Enter type _______________________________
5

Foreign identification (Complete only if item 3 is not applicable)

Passport

Foreign TIN

Other ________________

b Number

9

Mailing address (number, street, and apt. or suite no.)

Individual’s date of birth
MM/DD/YYYY

c Country of Issue
7 First name

Last name or organization name

10 City

Consolidated e

a Type:

6

14

Amended

Do not use previous editions of this form

Type of filer

a
3

___ ___ ___ ___

Do NOT file with your Federal Tax Return

(Rev. September 2013)

Part I

1 This report is for calendar
year ended 12/31

12

11 State

8 Middle initial

ZIP/Postal Code

8a Suffix

13 Country

a) Does the filer have a financial interest in 25 or more financial accounts?
Yes
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
Enter number of accounts __________ Complete Part IV, items 34 through 43 for each person on whose behalf the filer has signature authority.
No

Part II

Information on financial account(s) owned separately

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)
17

15a Amount 16 Type of account
unknown

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

20 City

21 State, if known

Signature
44

a

44a Check here

Filer signature
The report will be electronically
signed when filed

Third Party
Preparer
Use Only

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

22

Foreign postal code, if known

23 Country

if this report is completed by a third party preparer and complete the third party preparer section.
45

Filer title, if not reporting a personal account

47 Preparer’s last name

48 First name

52 Contact phone no.

52a Ext.

if
49 MI 50 Check
self-employed
53 Firm’s name

55 Mailing address (number, street, apt.or suite no.)

56 City

51 TIN
54 Firm’s TIN

46
Date (MM/DD/YYYY)
This date will auto-fill when the
FBAR is electronically signed
51a TIN type
PTIN
SSN/ITIN
54a TIN type

57 State 58 ZIP/Postal Code

Foreign
EIN
Foreign

59 Country

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 instructions
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 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 $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, P. O. Box 39, Vienna, VA 22183, Attn: Office of Regulatory Policy.

Rev 5.7 - 6/3/2013

Part III

Information on financial account(s) owned jointly

FinCEN Form 114
page number

Complete a separate block for each account owned jointly

_ of __

Add an additional Part III page as many times as necessary in order to provide information on all accounts
1 Filing for calendar
year

3-4 Check appropriate identification number

6 Last name or organization name

Taxpayer Identification Number
Foreign identification number
Enter identification number here:

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
unknown

16 Type of account

a

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

20 City

21 State, if known

24 Number of joint owners for this account

25 Taxpayer Identification Number (TIN) of principal joint owner, if known. See instructions

26 Last name or organization name of principal joint owner

22

Foreign postal code, if known

23 Country
25a TIN type
EIN
SSN/ITIN
Foreign

28 Middle initial, if known

27 First name of principal joint owner, if known

28a Suffix

29 Mailing address (number, street, apt. or suite no.) of principal joint owner, if known

31 State, if known

30 City, if known

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
unknown

16 Type of account

33 Country, if known

32 ZIP/Postal Code, if known

a

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. suite no.) of financial institution in which account is held

22

Foreign postal code, if known

20 City

21 State, if known

24 Number of joint owners for this account

25 Taxpayer Identification Number of principal joint owner, if known. See instructions

26 Last name or organization name of principal joint owner

27 First name of principal joint owner, if known

23 Country
25a TIN type
EIN
Foreign

SSN/ITIN

28 Middle initial, if known 28a Suffix

29 Mailing address (number, street, apt. or suite no.) of principal joint owner, if known

30 City, if known

31 State, if known

32 ZIP/Postal Code, if known

33 Country, if known

Part IV

Information on financial account(s) where filer has signature or other
authority but no financial interest in the account(s)

FinCEN Form 114
Page Number

Complete a separate block for each account

__ of __

Add an additional Part IV page as many times as necessary in order to provide information on all accounts
1 Filing for calendar
year

3-4 Check appropriate identification number

6 Last name or organization name

Taxpayer Identification Number
Foreign identification number
Enter identification number here:

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
unknown

16 Type of account

a

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

20 City

21 State, if known

22

Foreign postal code, if known

35 Tax identification number of account owner

34 Last name or organization name of account owner

36 First name

23 Country
35a TIN type
EIN
Foreign

SSN/ITIN

37 Middle initial 37a Suffix 38 Mailing address (number, street, and apt. or suite no.)

39 City

40 State

41 ZIP/Postal Code

42 Country

43 Filer’s title with this owner

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
Unknown

16 Type of account

a

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

20 City

21 State, if known

22

Foreign postal code, if known

35 Tax identification number of account owner

34 Last name or organization name of account owner

36 First name

39 City

43 Filer’s title with this owner

23 Country
35a TIN type
EIN
SSN/ITIN
Foreign

37 Middle initial 37a Suffix 38 Mailing address (number, street, and apt. or suite no.)

40 State

41 ZIP/Postal Code

42 Country

Part V

Information on financial account(s) where filer is filing a
consolidated report

FinCEN Form 114
Page Number

Complete a separate block for each account

__ of ___

Add an additional Part V page as many times as necessary in order to provide information on all accounts
1 Filing for calendar
year

3-4 Check appropriate identification number

6 Last name or organization name

Taxpayer Identification Number
Foreign identification number
Enter identification number here:

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
unknown

16 Type of account

a

Bank

b

Securities

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

20 City

21 State, if known

22

Foreign postal code, if known

23 Country
35a TIN type
EIN
SSN/ITIN
Foreign

35 Tax identification number of account owner

34 Organization name of account owner

38 Mailing address (number, street, Apt. or Suite No.)

39 City

40 State

15 Maximum value of account during calendar year
(See instructions under Monetary amounts, step 2)

17

15a Amount
unknown

41 ZIP/Postal Code

16 Type of account

a

Bank

b

Securities

42 Country

c

Other—Enter type below

Name of financial institution in which account is held

18 Account number or other designation

19

Mailing address (number, street, apt. or suite no.) of financial institution in which account is held

20 City

21 State, if known

22

Foreign postal code, if known

23 Country

35 Tax identification number of account owner

34 Organization name of account owner

35a TIN type
EIN
SSN/ITIN
Foreign

38 Mailing address (number, street, apt. or suite no.)

39 City

40 State

41 ZIP/Postal Code

42 Country