US. Department of Justice Request for Financial Information Under the Right to Financial Privacy Act (RFPA)
Washington, D.C. 20530 (Authorization, Purchase Order and Receiving Report)
This form shall be used when requesting financial records of individuals and partnerships of five or fewer individuals under die RFPA.
I Tracking Number j2 Date Order Prepared: 3 USAO Number:
Section A - Authorization and Purchase Order
N/A
4 Name and Address of Financial Institution: A.
Funding Certification & Budget Official Signature Funding Available Date
54-8113
Authorization: B.
Apprining Official Signature Date
5 Deliver Records To: Send Completed USA-21I Form & Invoice To: 6 Return Date:
V.S. Attorney's Office • SDNY
Budget 1Fiscal Unit
86 Clambers Street. led Floor New York. NY 10007
7 Remarks: Do not proceed with compliance if the total cost will exceed $ 500.00 without prior approval. To obtain approval. call the requestor listed in Item 8.
If invoicing for these services is expected to exceed 120 days. please notify the United States Attorneys Office immediately to ensure funds remain available
for payment. Please see the attached Important Notice for additional information on invoicing and other requirements for reimbursement.
8 Name of attestor Telephone Number 10 Date of request:
AUSA
Section B - Financial Institution Invoice
No Payment Shall Bc Made Unless Expenses Arc Itemized Below Or Set Forth On Your Attached Invoice.
IIA Invoice Number Unit Price
Quantity Amount
11B Tax ID Number: Cost Per
I IC Service(s)/Records Provided:
A. Searching and processing costs (clerical or technical personnel) $22.00 Hour
B. Searching and processing costs (management/supervisory personnel) 430.00 Hour
C. Searching and processing costs (computer support specialist) 430.00 Hour
D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if 40.25 Page
the information is stored electronically. unless the US Attorney's Office requests paper.
E. Reproduction Costs (Paper Copies of Microfiche: provide justification) 40.25 Frame
F. Reproduction Costs (Duplicate Microfiche: provide justification) S0.50 Microfiche
G. Storage Media Cost (e.g.. Compact Disc. DVD, etc.. at Actual Cost)
H. Transportation Costs (Direct Costs Only)
In Item 412. I certify that the services invoiced above were not performed relative to any corporate
accounts and pertain only to accounts of individuals and partnerships of five or fewer individuals.
12 Signature of Financial Institution Official: I3 Date Signed: Total Amount Claimed
By Financial Institution
16 Disallowance
Section C - Receiving Report
(See Attached)
14 I certify that the articles and services listed were received: 15 Date Received: 17 Net to
Financial
Institution
I8 Right to Financial Privacy Act - Public Law 95-630 I9 Signature of Approving Official:
(12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only)
OBJECT
SECTION CLASS
r, 3404 Customer Authorization 2545
✓ 3405 Administrative Subpoena or Summons 2545
20 Funding Source
✓ 3406 Search Warrant 2545
Accounting Code:
✓ 3407 Judicial Subpoena 2545
Program I
✓ 3408 Fomuil Written Request 2545 21 Other Accounting/Fund Information:
✓ 3413 Grand Jury Subpoena 2545 Program Code: NIA Project Code: NIA
n 3414 Special Procedures 2545
YREGDOC: 54-8113
Call Number (if applicable):
22 Remarks:
OBL Month (TRAM):
Tax ID Number.
To the of my knowledge. the financial records received. for which we are being billed. are those of an individual or partnership of five or fewer
FORM USA
-21I
FEB. 2014
Signature of United States Attorneys Office Repiesenkitive Date
EFTA00027224