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 A. | |||||||
| Funding Certification & Authorization: | Budget Official Signature Funding Available Date 54-8113 B. | |||||||
| Apprining Official Signature | Date | |||||||
| 5 Deliver Records To: V.S. Attorney’s Office • SDNY Budget 1 Fiscal Unit | Send Completed USA-21 I Form & Invoice To: 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 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 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 | ||||||
| Section C - Receiving Report | 16 Disallowance | |||||||
| 14 I certify that the articles and services listed were received: | 15 Date Received: | (See Attached) 17 Net to | ||||||
| Financial | ||||||||
| Institution | ||||||||
| I8 Right to Financial Privacy Act - Public Law 95-630 (12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only) | I9 Signature of Approving Official: | |||||||
| OBJECT | ||||||||
| SECTION r , 3404 | Customer Authorization | CLASS 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 Special Procedures 3414 | 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¶