## US. 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 be used when requesting financial records of individuals and partnerships of five or fewer individuals under the RFPA.

1 Tracking Number: <empty>
2 Date Order Prepared: <empty>
3 USAO Number: <empty>

Section A - Authorization and Purchase Order

4 Name and Address of Financial Institution:
Funding Certification & Authorization:
A.: N/A
Budget Official Signature Funding Available Date
B.: 54-8113
Approving Official Signature Date

5 Deliver Records To:
Send Completed USA-211 Form & Invoice To:
U.S. Attorney's Office - SDNY
Budget / Fiscal Unit
86 Chambers Street, 3rd Floor New York, NY 10007

6 Return Date: <empty>

7 Remarks: Do not proceed with compliance if the total cost will exceed $ 500.00 without prior approval. To obtain approval, call the requestor listed in Item 8.
If invoicing for these services is expected to exceed 120 days, please notify the United States Attorney's Office immediately to ensure funds remain available for payment. Please see the attached Important Notice for additional information on invoicing and other requirements for reimbursement.

8 Name of Requestor: AUSA
9 Telephone Number: <empty>
10 Date of request: <empty>

## Section B - Financial Institution Invoice

No Payment Shall Bc Made Unless Expenses Arc Itemized Below Or Set Forth On Your Attached Invoice.

11A Invoice Number: <empty>
11B Tax ID Number: <empty>

Quantity:
Unit Price Cost Per Amount
A. Searching and processing costs (clerical or technical personnel): <empty> $22.00 Hour <empty>
B. Searching and processing costs (management/supervisory personnel): <empty> $30.00 Hour <empty>
C. Searching and processing costs (computer support specialist): <empty> $30.00 Hour <empty>
D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if the information is stored electronically, unless the US Attorney's Office requests paper.: <empty> $0.25 Page <empty>
E. Reproduction Costs (Paper Copies of Microfiche: provide justification): <empty> $0.25 Frame <empty>
F. Reproduction Costs (Duplicate Microfiche: provide justification): <empty> $0.50 Microfiche <empty>
G. Storage Media Cost (e.g., Compact Disc, DVD, etc., at Actual Cost): <empty> <empty> <empty>
H. Transportation Costs (Direct Costs Only): <empty> <empty> <empty>

In Item #12, I certify 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 Official: <empty>
13 Date Signed: <empty>
Section C - Receiving Report
14 I certify that the articles and services listed were received: <empty>
15 Date Received: <empty>

Total Amount Claimed By Financial Institution

16 Disallowance (See Attached):<empty>

17 Net to Financial Institution:<empty>

18 Right to Financial Privacy Act - Public Law 95-630
(12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only)
SECTION:
[ ] 3404 Customer Authorization
[ ] 3405 Administrative Subpoena or Summons
[ ] 3406 Search Warrant
[ ] 3407 Judicial Subpoena
[ ] 3408 Formal Written Request
[ ] 3413 Grand Jury Subpoena
[ ] 3414 Special Procedures
OBJECT CLASS:
2545
2545
2545
2545
2545
2545
2545

19 Signature of Approving Official:<empty>

20 Funding Source:<empty>
Accounting Code:<empty>
Program:<empty>

21 Other Accounting/Fund Information:
Program Code: N/A
Project Code: N/A
YREGDOC: 54-8113
Call Number (if applicable):<empty>
OBL Month (YRMO):<empty>
Tax ID Number:<empty>

22 Remarks:<empty>

To the best of my knowledge, the financial records received, for which we are being billed, are those of an individual or partnership of five or fewer individuals.

Signature of United States Attorney's Office Representative:<empty>
Date:<empty>

FORM USA-21I
FEB. 2014

EFTA00027540