Washington, D.C. 20530

|                                                                                                                      | 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 |                                                                                                |                                                                         |                                                  |                                       |                                                                                  |  |
| 4 Name and Address of Financial Institution:                                                                         |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         | N/A<br>A.                                        |                                       |                                                                                  |  |
| Funding Certification &<br>Authorization:                                                                            |                                                                                                                                                                                                             |                                              |                                                                                                | Budget Official Signature<br>Funding Available<br>Date<br>54-8113<br>B. |                                                  |                                       |                                                                                  |  |
|                                                                                                                      |                                                                                                                                                                                                             |                                              | Apprining Official Signature                                                                   |                                                                         |                                                  | Date                                  |                                                                                  |  |
| 5 Deliver Records To:<br>V.S. Attorney's Office • SDNY<br>Budget 1 Fiscal Unit                                       |                                                                                                                                                                                                             |                                              | Send Completed USA-21 I Form & Invoice To:<br>86 Clambers Street. led Floor New York. NY 10007 |                                                                         | 6 Return Date:                                   |                                       |                                                                                  |  |
|                                                                                                                      | 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<br>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                                                                                                   |                                                                                                                                                                                                             |                                              | Quantity                                                                                       |                                                                         | Unit Price                                       |                                       | 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<br>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<br>By Financial Institution |                                       |                                                                                  |  |
| Section C - Receiving Report                                                                                         |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         | 16 Disallowance                                  |                                       |                                                                                  |  |
|                                                                                                                      | 14 I certify that the articles and services listed were received:                                                                                                                                           |                                              | 15 Date Received:                                                                              |                                                                         | (See Attached)<br>17 Net to                      |                                       |                                                                                  |  |
|                                                                                                                      |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         | Financial                                        |                                       |                                                                                  |  |
|                                                                                                                      |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         | Institution                                      |                                       |                                                                                  |  |
| I8 Right to Financial Privacy Act - Public Law 95-630<br>(12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only) |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         |                                                  | I9 Signature of Approving Official:   |                                                                                  |  |
|                                                                                                                      |                                                                                                                                                                                                             |                                              | OBJECT                                                                                         |                                                                         |                                                  |                                       |                                                                                  |  |
| SECTION<br>r<br>, 3404                                                                                               | Customer Authorization                                                                                                                                                                                      |                                              | CLASS<br>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<br>Special Procedures<br>3414                                                                                      |                                                                                                                                                                                                             |                                              | 2545                                                                                           | YREGDOC:<br>54-8113<br>Call Number (if applicable):                     |                                                  |                                       |                                                                                  |  |
| 22 Remarks:                                                                                                          |                                                                                                                                                                                                             |                                              |                                                                                                |                                                                         |                                                  |                                       |                                                                                  |  |
|                                                                                                                      |                                                                                                                                                                                                             |                                              |                                                                                                | OBL Month (TRAM):<br>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