U.S. 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 o fewer individuals under the REPA. 1 Tracking Number: 2 Date Order Prepared: 3 USAO Number: Section A - Authorization and Purchase Order N/m 4 Name and Address of Financial Institution: A Funding Certification & Budget Official Signature Funding Available Date . 54-8113 Authorization: B. Approving Official Signature Date 5 Deliver Records To: Send Completed USA-211 Form & Invoice To: 6 Return Date: U.S. Attorney's Office - SDNY Budget / Fiscal Unit 86 Chambers Street, 3rd 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 Attorney's 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. & Name of Requestor Telephone Number: 10 Date of request: aus Pe Section B - Financial Institution Invoice No Payment Shall Be Made Unless Expenses Are Itemized Below Or Set Forth On Your Attached Invoice. ILA Invoice Number: Unit Price Quantity Amount 1IB Tax ID Number: Cost Per IC Service(sWRecords Provided: A. Searching and processing costs (clerical or technical personnel) [| $22.00 Hour tC B. Searching and processing costs (managemenUsupervisory personnel) [| $30.00 Hour Li C. Searching and processing costs (computer support specialist) a $30.00 Hour [| D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if [| $0.25 Page ;té«~«Y the information is stored electronically, unless the US Attorney's Office requests paper. E. Reproduction Costs (Paper Copies of Microfiche: provide justification) [| $0.25 Frame F. Reproduction Costs (Duplicate Microfiche: provide justification) [| $0.50 Microfiche G. Storage Media Cost (e.g., Compact Disc, DVD, etc., at Actual Cost) [ [ | [ | H. Transportation Costs (Direct Costs Only) | es |) | In Item #12, 1 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: 13 Date Signed: Total Amount Claimed By Financial Institution 5 7 , 16 Disallowance Section C - Receiving Report (See Attached) 14 I certify that the articles and services listed were received: 15 Date Received: 17 Netto Financial l Institution 18 Right to Financial Privacy Act - Public Law 95-630 19 Signature of Approving Official: (12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only) OBJECT SECTION CLASS r 3404 Customer Authorization 2545 20 Funding Source | 3405 Administrative Subpoena or Summons 2545 . Accounting Code: r PF 3406 Search Warrant 2545 fr 3407 Judicial Subpoena 2545 Program a cr r 3408 Formal Written Request 2545 21) Other Accounting/Fund Information: 3413 Grand Jury Subpoena 2545 Program Code: N/A Project Code: N/A 3414 Special Procedures 2545 YREGDOC: 54-8113 22 Remarks: Call Number (if applicable): OBL Month (YRMO): Tax ID Number: To the best of my knowledge, the financial records received, for which we are being billed. are those of an indivedual or partnership of five or fewer individuals. FORM USA-211 Signature of United States Attorney's Olfice Representative Date FER. 2004 EFTA00027224