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 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 USDA-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 Be Made Unless Expenses Are Itemized Below Or Set Forth On Your

Attached

Invoice.

## Section B - Financial Institution Invoice (cont.)

<table><tr><th>11A Invoice Number:</th><th></th><th rowspan="2" colspan="2">Quantity</th><th colspan="2">Unit Price</th><th rowspan="2">Amount</th></tr><tr><td>11B Tax ID Number:</td><td></td><td>Cost</td><td>Per</td></tr><tr><td colspan="3">11C Service(s)/Records Provided:</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">A. Searching and processing costs (clerical or technical personnel)</td><td></td><td>$22.00</td><td>Hour</td><td></td></tr><tr><td colspan="3">B. Searching and processing costs (management/supervisory personnel)</td><td></td><td>$30.00</td><td>Hour</td><td></td></tr><tr><td colspan="3">C. Searching and processing costs (computer support specialist)</td><td></td><td>$30.00</td><td>Hour</td><td></td></tr><tr><td colspan="3">D. Reproduction Costs (Photocopying) - **Note: Copy charges will be disallowed if</td><td></td><td>$0.25</td><td>Page</td><td></td></tr><tr><td colspan="3">the information is stored electronically, unless the US Attorney's Office requests paper.</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">E. Reproduction Costs (Paper Copies of Microfiche: provide justification)</td><td></td><td>$0.25</td><td>Frame</td><td></td></tr><tr><td colspan="3">F. Reproduction Costs (Duplicate Microfiche: provide justification)</td><td></td><td>$0.50</td><td>Microfiche</td><td></td></tr><tr><td colspan="3">G. Storage Media Cost (e.g., Compact Disc, DVD, etc., at Actual Cost)</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">H. Transportation Costs (Direct Costs Only)</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">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.</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">12 Signature of Financial Institution Official:</td><td colspan="2">13 Date Signed:</td><td colspan="2">Total Amount Claimed
By Financial Institution</td><td></td></tr><tr><td colspan="4">Section C - Receiving Report</td><td colspan="2">16 Disallowance
(See Attached)</td><td></td></tr><tr><td colspan="3">14 I certify that the articles and services listed were received: 15 Date Received:</td><td></td><td>17 Net to
Financial
Institution</td><td></td><td></td></tr><tr><td rowspan="2" colspan="3">18 Right to Financial Privacy Act - Public Law 95-630 19
(12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only)
OBJECT</td><td></td><td>Signature of</td><td>Approving Official:</td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td>SECTION</td><td></td><td>CLASS</td><td></td><td></td><td></td><td></td></tr><tr><td>3404</td><td>Customer Authorization</td><td>2545</td><td>20</td><td>Funding Source</td><td></td><td></td></tr><tr><td>3405</td><td>Administrative Subpoena or Summons</td><td>2545</td><td>Accounting</td><td>Code:</td><td></td><td></td></tr><tr><td>3406</td><td>Search Warrant</td><td>2545</td><td></td><td></td><td></td><td></td></tr><tr><td>3407</td><td>Judicial Subpoena</td><td>2545</td><td rowspan="2" colspan="4">Program
21 Other Accounting/Fund Information:
Code: N/A Project Code: N/A</td></tr><tr><td>3408</td><td>Formal Written Request</td><td>2545</td></tr><tr><td>3413</td><td>Grand Jury Subpoena</td><td>2545</td><td>Program</td><td></td><td></td><td></td></tr><tr><td>3414</td><td>Special Procedures</td><td>2545</td><td>YREGDOC:</td><td></td><td>54-8113</td><td></td></tr><tr><td>22 Remarks:</td><td></td><td></td><td>Call
OBL</td><td>Number (if
Month (YRMO):</td><td>applicable):</td><td></td></tr><tr><td></td><td></td><td></td><td>Tax ID</td><td>Number:</td><td></td><td></td></tr></table>

## Section B - Financial Institution Invoice (cont.)

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

Date

FORM USA-211
FEB. 2014

EFTA00028301