EFTA00186821¶
U.S. Department of Justice Washington, D.C. 20530¶
Request for Financial Information (Authorization, Purchase Order, Receiving Report)¶
This form shall only be used when requesting financial records of individuals ad partnerships of five or fewer individuals.¶
1 Purchase Order Number: 2 Date Order Prepared: 2/14/2007 3 Case Number: (Optional) FGJ 07-103(WPB) No. OLY-32¶
Section A - Authorization and Purchase Order¶
4 Name and Address of Financial Institution: JP Morgan Chase¶
5 Deliver To: FBI Special Agent¶
6 Return Date: 3/6/2007¶
7 Remarks: FOR REIMBURSEMENT PLEASE RETURN THIS FORM, THE RECORD OF SERVICES, AND A COPY OF THE SUBPOENA.¶
8 Name of Requester (Type or Print): Telephone Number: 10 Date of request: 2/14/2007¶
Section B - Financial Institution Invoice¶
No Payment Shall Be Made Unless Expenses Are Itemized Below Or On Your Form To Be Attached.¶
11 Service/Financial Records Provided:¶
FOR PROMPT PAYMENT INCLUDE TAX LD. NUMBER. 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.¶
Do not proceed with compliance: If cost will exceed $580 without prior approval of Budget Officer Lazaro Feliciana. Fax any request to (305) 530-7679¶
12 Signature of Financial Institution Official: 13 Date Signed: Total Amount Claimed By Financial Institution 0.00¶
Section C - Receiving Report¶
14 I certify that the articles and services listed were received: 15 Date Received: Net 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 2540 □ 3405 Administrative Subpoena or Sammonos 2541 □ 3406 Search Warrant 2542 □ 3407 Judicial Subpoena 2543 □ 3408 Format Written Request 2544 □ 3413 I Grand Jury Subpoena 2545 □ 3414 Special Procedures 2546¶
19 Signature of Approving Official:¶
20 Accounting Classification Code¶
FY FC 1 2 3 4 5 PROJ¶
21 Schedule and Voucher Number: DC#¶
22 Remarks:¶
□ Funds Available¶
Date: Budget Officer:¶
This form was electronically produced by Ellie Federal Form, Inc.¶
EFTA00186822¶
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 XI, 12 U.S.C. 3415.¶
NOTE:¶
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 date of the check issued in payment shall be considered to be the date payment is made.¶
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 provisions 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 requestingofficial).¶
ITEM 4 - Enter the name and mailing address of the financial institution being requested to furnish financial information.¶
ITEM 5 - Enter the name and address to which the financial information is to be sent by the financial institution. This will normally be the name and address of the requesting official.¶
ITEM 6 - Enter the date 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 intitution).¶
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.¶
ITEM 12 and 13 - Self-explanatory.¶
SECTION C - RECEIVING REPORT (To be completed by the requesting official, whenthe 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.¶