FBAR Questionnaire - gollobcpa.com

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Did you have a financial interest in or signature authority over a financial account such as a bank account, securities account, or brokerage account, located in a foreign country?(Required)

Yes

If you don’t have a foreign bank account, you do not need this form.

Foreign Bank Account Information

Please enter the information in the space provided below for your foreign bank account. It is required to file for any foreign account that was over $10,000 at any point during the current year. For consistency purposes, if an account that was previously reported goes below the filing threshold, we still advise you to include it.

**if we have the account on file from previous years, we only need the account number and maximum value. You do not need to give the bank name, address, or ownership information.

Name(Required)

First Middle Last

Account 1

Has this account been filed by us in previous years?(Required)

Yes

Type of Account

Bank

Investment

Retirement

This account is owned by:(Required)

If Other, please specify:

Maximum value of account for current year:(Required)

Preferred Currency for the account:(Required)

Bank Name(Required)

Account Number(Required)

If we have previously filed this account, you only need to provide the last four digits.

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this account for a business?

Yes

Do you have signature authority over this business account?

Yes

If yes, please provide the following information.

SSN/EIN/TIN of Business (if applicable):

Foreign ID Number of Account Holder (If Applicable):

Principal Account Holder (First & Last Name or Organization):

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your title with this company/relationship to owner of account:

Do you have more foreign bank accounts to add?

Yes

Account 2

Has this account been filed by us in previous years (Account 2)?(Required)

Yes

Type of Account (Account 2)

This account (Account 2) is owned by:

If Other, please specify (Account 2):

Maximum value of account for current year (Account 2):

Preferred Currency for the account (Account 2):

Bank Name (Account 2)

Account Number (Account 2)

If we have previously filed this account, you only need to provide the last four digits.

Bank Address (Account 2)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Account 2 for a business?

Yes

Do you have signature authority over this business (Account 2)?

Yes

If yes, please provide the following information.

SSN/EIN/TIN of Business Account 2 (if applicable):

Foreign ID Number of Account 2 Holder (If Applicable):

Principal Account 2 Holder (First & Last Name or Organization):

Address (Account 2)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your title with this company/relationship to owner of Account 2:

Do you have another foreign bank account to add?

Yes

Account 3

Has this account been filed by us in previous years (Account 3)?(Required)

Yes

Type of Account (Account 3)

This account (Account 3) is owned by:

If Other, please specify (Account 3):

Maximum value of account for current year (Account 3):

Preferred Currency for the account (Account 3):

Bank Name (Account 3)

Account Number (Account 3)

If we have previously filed this account, you only need to provide the last four digits.

Bank Address (Account 3)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Account 3 for a business?

Yes

Do you have signature authority over this business (Account 3)?

Yes

If yes, please provide the following information.

SSN/EIN/TIN of Business Account 3 (if applicable):

Foreign ID Number of Account 3 Holder (If Applicable):

Principal Account 3 Holder (First & Last Name or Organization):

Address (Account 3)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your title with this company/relationship to owner of Account 3: