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 he used whose and recerds of individuals and spanceships of tive or fewer individuals unlar the RPPA 2 Date Order Propared: 3 USAO Number: Section A - Authorization and Purchase Order 1 4 Name and Address of Financial Institution: Retail Bank Operations Budget Offical Signatura Punding Certification & building Available 54-8113 PO Box 1377 Authorization! ewiston ME 04243-137 Approving Official Signatus Duta 5 Deliver Records To: Send Completed USA-2 Form & Invoice To: 6 Return Date: See attached subpoena for delivery Instructions Budget / Fiscal Unit See attached 86 Churnberx Street, 3rd Pioor Now York, NY 10007 without prior approval. To obtuin approvul, call the requestor listed in Item 8. Do not proceed with compliunes if the total cost will exceed $ 500.00 If invicing for these scrowed to exceed 120 days, please notify the United Suzes Altorney's Office intentials to answe finds remain available for onement, Please see the attached Intrornation on invoicing and other requirements for relinivations 8 Name of Roguestory 9 Tolophone Number: 10 Date of tequest: AUSA 8/19/2019 Section B = Financial Institution Invoice 4284513574 Ref 172806 No Payment Shall Bo Made Unless Expenses Are Itemized Below Or Set Forth On Your Attactied Involce IIA Invoice Number: Unit Price Quantity Amount Cost Per 11C Service(s)/Records Provided: A. Scarching and processing costs (clerical or technical personnel) 1.5 $22.00 $33.00 Hour B. Searching and processing costs (management/supervisory personnel) $30.00 Hour C. Searching and processing costs (computer support specialist) $30.00 Hour D. Reproduction Costs (Photocopying) - " " Note: Copy charges will be disallowed if $0.25 Page the information is stored electronically, unless the US Attorney's Office requests paper. E. Reproduction Costs (Paper Copies of Microfiche; provide justification) SO.25 Frame F. Reproduction Costs (Duplicate Microfiche: provide justification) $0.50 Microfich G. Storage Media Cost (e.g., Compact Disc, DVD, etc., al Actual Cost) $0.75 CD $0.75 H. Transportation Costs (Direct Costs Only) In Item #12, I cortify 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 Offic 13 Date Signed: Total Amount Claimed By Financial Institution 08/27/19 $33.75 6 Disallowance Section C - Receiving Report (Seu Attached) 14 I certify that the unlicles and services listed were received: 17 Net to IS Date Received: Financial mostitution 18 Right to Financial Privacy Act - Public Law 95-630 19 Signature at Approving Official: (12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only OBJECT SECTION CLASS Cuslomer Authorization 3404 2545 20 Funding Source Administrative Subpoena or Summons 3402 2545 Accounting Code: Search Warrant 3400 2545 Program Judicial Subpocha 3407 2545 21 Other Accounting/Fund Information: Formal Written Request 3408 2545 Grand Jury Subpoena Program Codo: N/A Project Cade: N/A 3413 2545 YREODOC: 3414 Special Procedures 54-8113 2545 Call Number (if applicuble): 22 Remarks: OBL Month (YRMO): Tax ID Number: To five of my knowledge, the first in conds received, for which we re bring hilled, and list individual or partnership of five or fever individuals | |||||
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| 1 Tracking Number! | |||||
| TD Bank N.A. | Date | ||||
| 7 Rematks: | |||||
| IIB Tax ID Number: | |||||
Signature of United Status Amomey's Office Representative¶
FORM USA-21 L FEB. FEB. 2014¶
TOTAL P.007¶