EFTA00123545¶
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: JP Morgan Chase 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 $500.00 without prior approval. To obtain approval, call the requester listed in Item 8. If invoking 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 Reporter: AUSA¶
9 Telephone Number: 11/22/2019¶
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 Service(s)/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 Purpose To: Check One Only)¶
SECTION 3404 Customer Authorization 3405 Administrative Subpoena or Summons 3406 Search Warrant 3407 Judicial Subpoena 3408 Formal Written Request 3409 Grand Jury Subpoena 3414 Special Procedures¶
OBJECT CLASS 2545 2545 2545 2545 2545 2545¶
20 Funding Source Accounting Code: Program 21 Other Accounting/Fund Information: Program Code: N/A Project Code: N/A YREGDC: 54-8113¶
Call Number (if applicable): OBL Mouth (YRMO): 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¶
EFTA00123546¶