Form 14454
(December 2017)
OMB Number
1545-2241
Catalog Number 61606G www.irs.gov
Form 14454 (Rev. 12-2017)
Department of the Treasury–Internal Revenue Service
Attachment to Offshore Voluntary Disclosure Letter
(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. Address, including country, where the account was established (If different, address,
including country, where account is currently located)
3. Date the account was opened DO NOT LEAVE BLANK
(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