14654 Form 2016

Attach a continuation sheet if necessary. If you attach a continuation sheet it must be signed with taxpayer name s and TIN s printed. Catalog Number 67044W www.irs.gov Form 14654 Rev. 6-2016 Page 2 of 5 Note Use this seventh year only if your 3-year covered tax return period does not completely overlap with your 6-year covered FBAR period for example if your 3-year covered tax return period is 2011 through 2013 because the due date for your 2013 tax return is passed but your covered FBAR period is 2007 through 2012 because the due date for the 2013 FBAR has not passed. Department of the Treasury - Internal Revenue Service Form 14654 Certification by U.S. Person Residing in the United States June 2016 for Streamlined Domestic Offshore Procedures Name s of taxpayer s TIN s of taxpayer s Mailing address City OMB Number 1545-2241 Telephone number State ZIP code Note If this certification is a joint certification the statements will be considered made on behalf of both spouses even though the pronoun I is used. If spouses submitting a joint certification have different reasons for their failure to report all income pay all tax and submit all required information returns including FBARs they must state their individual reasons separately in the required statement of facts. Certification I am providing amended income tax returns including all required information returns for each of the most recent 3 years for which the U*S* tax return due date or properly applied for extended due date has passed* I previously filed original tax returns for these years. The tax and interest I owe for each year are as follows Year list years in order Amount of Tax I Owe Form 1040X line 19 Interest Total I failed to report income from one or more foreign financial assets during the above period. I meet all the eligibility requirements for the Streamlined Domestic Offshore procedures. If I failed to timely file correct and complete FBARs for any of the last 6 years I have now electronically filed those FBARs. During each year in either my 3-year covered tax return period or my 6-year covered FBAR period my foreign financial assets subject to the 5 miscellaneous offshore penalty were as follows Name City and Country of Financial Institution/Description of Asset Account Number Year Account Was Opened or Asset Was Acquired Year-End Balance/ Asset Value state in US Dollars If you held no assets subject to the 5 miscellaneous offshore penalty during this year enter N/A next to Total in the above table. The assets listed in this certification are my only foreign financial assets subject to the 5 miscellaneous offshore penalty. My penalty computation is as follows Highest Account Balance/Asset Value enter the highest total balance/ asset value among the years listed above Miscellaneous Offshore Penalty Highest Account Balance/Asset Value from above multiplied by 5 My payment information is as follows Total Tax and Interest Due Total Payment Note Your payment should equal the total tax and interest due for all three years plus the miscellaneous offshore penalty.