EFTA00109012

U.S. Department of Justice

Washington, D.C. 20530

Request for Financial Information Under the Right to Financial Privacy Act (RFPA) (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 the RPPA.

1 Tracking Number: 2 Date Order Prepared: 3 USAO Number:

Section A - Authorization and Purchase Order

4 Name and Address of Financial Institution:
Credit One Bank
Funding Certification & Authorization:

5 Deliver Records To:
See attached subpoena for delivery instructions

6 Return Date:
See attached

7 Remarks:
Do not proceed with compliance if the total cost will exceed $5,000.00 without prior approval. To obtain approval, call the requester 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.

8 Name of Recipient:
AUSA

9 Telephone Number:
10 Date of request:
10/02/2019

Section B - Financial Institution Invoice

No Payment Shall Be Made Unless Expenses Are Itemized Below Or Set Forth On Your Attached Invoice.

11A Invoice Number:
11B Tax ID Number:
11C Services/Records Provided:
A. Searching and processing costs (clerical or technical personnel)
B. Searching and processing costs (management/supervisory personnel)
C. Searching and processing costs (computer specialist)
D. Reproduction Costs (Photocopying) **Note: Copy charges will be disallowed if the information is stored electronically, unless the US Attorney's Office requests paper.
E. Reproduction Costs (Paper Copies of Microfiche: provide justification)
F. Reproduction Costs (Duplicate Microfiche: provide justification)
G. Storage Media Cost (e.g., Compact Disc, DVD, etc., at Actual Cost)
H. Transportation Costs (Direct Costs Only)

In Item #12, 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:
13 Date Signed:
Total Amount Claimed By Financial Institution

Section C - Receiving Report

14 I certify that the articles and services listed were received:
15 Date Received:
16 Disallowance (See Attached)
17 Not to Financial Institution

18 Right to Financial Privacy Act - Public Law 95-630
(12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only)

OBJECT CLASS
3404 Customer Authorization
3405 Administrative Subpoena or Summons
3406 Search Warrant
3407 Judicial Subpoena
3408 Format Written Request
3409 Grand Jury Subpoena
3414 Special Procedures

19 Signature of Approving Official:

20 Funding Source
Accounting Code:
Program

21 Other Accounting/Fund Information:
Program Code: N/A
Project Code: N/A
YRREGDC:
54-8113

Call Number (if applicable):
OBL Mouth (YRM0):
Tax ID Number:

To the best of my knowledge, the financial records received, for which we are being billed, are those of an individual or partnership of five or fewer individuals.

Signature of United States Attorney's Office Representative



FORM USA-211
FEB. 2014


Date

EFTA00109013