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Eparate Statement for each foreign account or asset included in your voluntary disclosure. At least one Statement must be submitted. Respond to each applicable question in the space provided attachments are appropriate should additional space be necessary. 1 2 3 Name of Foreign Financial Institution Country where Institution is Located Contact Person at this Institution YES 4 5 6 7 NO Is the offshore account a bank account holding cash, money market, or CD? Is the offshore account a custo.

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