DOJ financial records request form to a bank, August 2006

EFTA00185533¶

AUG 09 2006 11:39 FR FRAUD DSRU 08/09/2006 WED 11:30 FAX¶

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U.S. Department of Justice¶

Washington, DC 20501¶

Request for Financial Information (Authorization, Purchase Order, Receiving Report)¶

File from shall only be used when requesting financial records of individuals and partnerships of fow or brow individuals.¶

1. Purchase Order Number: 1962-1011
   • Date Order Prepared: 08/02/2006
   • Case Number: FGJ 05-02(WEB) NO.051-03 (OLY-03)

Section A - Authorization and Purchase Order¶

4. Name and Address of Financial Institution: Artin; Subpoena Compliance

   • Capital One, 15000 Capital One Drive, Richmond, VA 23238 - Fax 888-259-3021

5. Deliver To: Special Agent

   • Federal Bureau of Investigation, 505 South Flagler Drive,
   • Suite 500, Florida 33401, Tel.:

6. Remarks: FOR REINSURMENT PLEASE RETURN THIS FORM, THE RECORD OF SERVICES, AND A COPY OF THE SUBPOENA.

7. Name of Requester: (Type or Print)

   • AUSA

8. Telephone Number: 10 Date of request: 08/02/2006

Section B - Financial Institution Invoice¶

No Payment shall be made unless Expenses are Implanted Below Or On Your Form To Be Amended.¶

Service/Financial Records Provided	Quantity	Unit Price	Amount
Please note that reimbursement cannot be made for the records pertaining to corporations or large partnerships of six or more. IMPORTANT: The DCIA Mandates the use of EPT/DD. In order to receive payment complete the attached EPT enrollment Form.		0.25	Copy
		11.00	Hour Clinical Tech
		17.00	Hour Manager or Supervisor

Do not present with camperies. If cost will exceed $300 without prior approval of AMERICAN AMBULANCE RESPONDING OFFICE. PLEASE REFERENCE THE ABOVE DCN8 ON YOUR INVOICE FOR PAYMENT.¶

12a. Signature of Financial Institution Official: 12b. Phone of Financial Institution Official: 13d. Signature: Total Amount Claimed By Financial Institution 16. Disclosure (See Attached)¶

Section – Receiving Report¶

14. I certify that the articles and services listed were received:

15. Date Received: 17 Not to Financial Institution

16. Right to Financial Privacy Act - Public Law 85-430 (12 U.S.C. 3014-342) Request Permanent Tc (Check One Only) SECTION

17. Signature of Approval Officer:

18. Accounting Classification Code

19. Schedule and Voucher Number DCN

20. Remarks:

• Funds Available
• Date
• Badge Officer

This form was electronically produced by Eliza Federal Forms, Inc.¶

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GENERAL¶

This is a multi-purpose form designed to serve as an Authorization, Purchase Order, Itemized Invoice, receiving Report and Payment voucher in conjunction with “requests for financial information,” pursuant to the Right to Financial Privacy Act of 1978, P.L. 95-630, Title XL, 12 U.S.C. 3415.¶

Payments under this purchase order will be due on the 30th calendar day after the date of actual receipt of a proper invoice in the office designated to receive the invoice.¶

The Prompt Payment Act, Public Law 97-177, 96 Stat. 85 (31 U.S.C. 180), is applicable to payments under this purchase order and requires the payment to contractors of interest or overdue payments and improperly taken discounts. Determination of interest due will be made in accordance with the provision of the Prompt Payment Act and the Office of Management and Budget Circular A-125.¶

PREPARATION INSTRUCTIONS¶

ITEM 1 - A Purchase Order Number will be preprinted on each form. This number will be used for reference purposes on any correspondence relating to this specific request for financial information.¶

ITEM 2 - Self explanatory.¶

ITEM 3 - This block may be used to identify the specific case for which the financial information is required. This block may be left blank.¶

SECTION A - AUTHORIZATION AND PURCHASE ORDER (To be completed by the requesting official).¶

IBM 4 - Enter the name and mailing address of the financial institution being requested to furnish financial information.¶

ITEM 5 - Enter the and address to which the financial information is to be sent by the financial institution. This will normally be the name and the address of the requesting official.¶

ITEM 6 - Enter the date the financial information is required.¶

IBM 7 – Include, if appropriate, any pertinent information related to the purchase order not provided for elsewhere on the form.¶

ITEM 14 and 15 - Self-explanatory.¶

ITEM 8, 9 and 10 - Self-explanatory.¶

SECTION C - RECEIVING REPORT (To be completed by the requesting official, when the requested financial information has been delivered).¶

SECTION B - FINANCIAL INSTITUTION INVOICE (To be completed by the financial institution),¶

ITEM 11 - Self-explanatory. Completion of this block constitutes an itemized bill or invoice for reimbursement for the costs incurred in providing the information requested. The DCIA Mandates the use of EFT/DD. In order to receive payment complete the attached EFT enrollment Form.¶

ITEM 16 - This block should be used to reflect any differences between the amount claimed by the financial institution and the correct amount to be reimbursed. Differences may result from computation errors, or failure of the financial institution to deliver information requested.¶

ITEM 12 and 13 - Self-explanatory.¶

ITEM 17 - Enter the amount certified to be proper for payment.¶

ITEM 18 - Check the box which identifies the appropriate procedure authorized by the Act, which necessitates the request for financial information.¶

ITEM 19 and 20 - These blocks must be signed and dated by an official of the organization whose funds will be charged. His or her signature constitutes a statement that the records to which the invoice refers were required for official business and were provided by the financial institution in accordance with the ordering instrument.¶

ITEM 21 - The Schedule and Voucher Number will be entered by the office which actually schedules the approved amount for payment by the Treasury Department.¶

ITEM 22 - Enter, if appropriate, any data not provided for elsewhere on the receiving report, such as, reasons for any claim amounts disallowed.¶

FORM CED-311 APR. 84 Page 2 of 3¶

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VENDOR ELECTRONIC FUNDS TRANSFER (EFT) ENROLLMENT FORM¶

Please comply to this information if you have not done so already¶

PAYEE/COMPANY INFORMATION:¶

Vendor Company Name:
Address:
Taxpayer ID Number
Contact Person Name
Telephone Number
E-mail Address(If you would like to be notified via e-mail)

Bank Name
Bank Address
Bank Phone Number
Nine Digit ABA Routing Transit Number
Type of Account(Checking or Saving)
Depositor Account Number
Signature of Vendor's Authorizing Official
Name & Title of Authorizing Official

Please Return or Fax to:¶

U.S. Attorney’s Office¶

Southern District of Florida¶

99 NE 4 street, Suite 200¶

Miami, FL. 33182¶

Attention:¶

Fax Number:¶

The Debt Collection Improvement Act of 1995 requires that payments made by the Federal government, including vendor payments, must be made by electronic funds transfer (EFT). A benefit of receiving payments by EFT is that your funds are directly deposited to your account at a financial institution and are available to you on the date of payment.¶

If you have questions regarding the delivery of the remittance information, please contact the financial institution where your account is held.¶

If you have any questions on the completion of this form, please contact¶

FORM 4 CBD-211 APR. 84 Page 3 of 3¶