EFTA00185536 AUG 09 2006 11:40 FR FRAUD DSRU 08/08/2006 TW 24:94 40F Request for Financial Information (Authorization, P. 07 # Purchase Order, Receiving Report ## Section A - Authorization and Purchase Order 4 Names and Address of Financial Institution: ATM Subpoena Compliance Capital One, 15000 Capital One Drive, Richmond, VA 22338 - Fax 888-259-3021 5 Delivery To: Special Agent Nehtil Kuvykendall, Federal Bureau of Investigation, 505 South Flipter Drive, Suite 500, Florida 33403, Tel.: 7 Reworks: FOR REIMBURSEMENT PLEASE RETURN THIS FORM, THE RECORD OF SERVICES, AND A COPY OF THE SUBPOENA. 8 Name of Requester: (Type or Profit) AUUSA 9 Telephone Number: 10 Date of request: 08/02/2006 ## Section B - Financial Institution Invoice No Payment shall Be Made Unless Expenses Are Immediately Below Or On Your Poem To Be Attached. ### 11 Service/Financial Records Provided: | Quantity | Unit Price | Amount | | :--- | :--- | :--- | | | Cost | Fee | | 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 EFT/DD. In order to receive payment complete the attached EFT enrollment Form. | 0.25 | Copy | | | 11.00 | Hour Clerical Tech | | | 17.00 | Hour Manager or Supervisor | Do not record with compliance; if cost will exceed $300 without prior approval of Assistant U.S. Attorney/Budget Officer. PLEASE REFERENCE THE ABOVE DCW ON YOUR INVOICE FOR PAYMENT. ### 12 Signature of Financial Institution Official: 12b Please of Financial Institution Official: 13 Date Signed: Total Amount Claimed By Financial Institution ### 14 I certify that the articles and services listed were received: 15 Date Received: Not to Financial Institution ### 15 Right to Financial Privacy Act - Public Law 52-638 (12 U.S.C. 3401-3422) Request Permanent Tc (Check One Only) **OBJECT CLASS** - 3404 Customer Authorization - 3405 Administrative Subpoena or Simulations - 3406 Samb Warrant - 3407 Judicial Subpoena - 3408 Formal Written Request - 3413 I Grand Jury Subpoena - 3414 Special Procedures ### 19 Signature of Approval Official: - 80 Accounting Classification Code - FY PC 1 2 3 4 5 PRO1 ### 21 Schedule and Voucher Number: DC# ### 22 Rewrites: - Funds Available - Date - Budget Officer This item was electronically produced by Ellie Federal Forms, Inc. EFTA00185537 AUG 09 2006 11:40 FR FRAUD DSRU TO P.08 ## GENERAL This is a multi-purpose form designed to serve as an Authorization, Purchase Order, formized 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 Budge 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). ITEM 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 data the financial information is required. ITEM 7 - Include, if appropriate, any pertinent information related to the purchase order not provided for elsewhere on the form ITEM 8,9 and 10 - Self-explanatory. SECTION B - FINANCIAL INSTITUTION INVOICE (To be completed by the financial institution). ITEM 11 • Self-explanatory. Completion of this block constitutes an loanized 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 12 and 13 - Self-explanatory. SECTION C - RECEIVING REPORT (To be completed by the requesting official), when the requested financial information has been delivered). ITEM 14 and 15 - Self-explanatory. 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 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 CHD-211 APR. 04 Page 2 of 3 EFTA00185538 AUG 09 2006 11:40 FR FRAUD DSRU 08/08/2006 NEW ALIVE B TO P.09 ## 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)
FINANCIAL INSTITUTION INFORMATION:
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 89 NE 4 street, Suite 200 Miami, FL. 33132 Attention: ## Fax Number: The Debt Collection Improvement Act of 1996 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 Claudia Castellanos, et FORM OGB-211 APR 84 Page 3 of 3 ** TOTAI PAGE.99 **