This is an FBI investigation document from the Epstein Files collection (FBI VOL00009). Text has been machine-extracted from the original PDF file. Search more documents →
FBI VOL00009
EFTA01075176
162 pages
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Pitted States District " loud SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 05-02(WPB)-Fri./No. OLY-13 • SUBPOENA FOR: PERSON pi DOCUMENTS OR OBJECT[S] X 1,3 YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: Palm Beach County Courthouse Juvenile Courts Building 205 N. Dixie Highway West Palm Beach, Florida 33401 (Temporary location for the United States District Courthouse, West Palm Beach) ROOM: Room 4-A DATE AND TIME: September 8, 2006 11:00am YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): Please coordinate your compliance of this subpoena and confirm the date and time of your appearance with Special Agent' 'Federal Bureau of Investigation, Telephone:I b3 b6 b7C This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. CLERK (BY) DEPUTY CLERK O pits Otaro le.e. DATE: September 1, 2006 This subpoena is issued upon application of the United States of America *If not applicable, enter 'none.' me, A4 ess Number of Assistant U.S. Attorney Assistant U.S. Attorney 500 So. Australianrem; Suite 400 West Palm Beach, L 33401-6235 Tel: Fax: 316., w Fot o& A- To be =disks of A0110 EFTA01075216
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JAN.86 IP IIIP RETURN OF SERVICE' RECEIVED BY SERVER DATE / 1 0 (1/0// 0 4 PLACE J a c-- 4 1/4\ ve?„..C2 v,a 3 ...ti crt \- SERVED DATE / / 0 410 I/0 te - PLACE ( I 'e sk B'\ Y1-• ttl29-3 \ F. C - / SERVED ON (NAME) b3 SER TITLE S e Csck0 . ev\--\--- STATEMENT OF SERVICE FEES TRAVEL SERVICES TOTAL b6 b7C DECLARATION OF SERVICE' I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct. Executed on 6 40(O i DA ' gbc. S. FlOtielZa r (J 4 t.S-0t (Al PAz R- Address of Server ADDITIONAL INFORMATION • 1.M to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(e), Federal Rules of Civil Procedure. 2."Fees and mileage need not be tendered to the witness upon service of a subpoena issued on behalf of the United States or an officer or agency thereof (Rule 45(e), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075217
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Untied States District Cat SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 05-02(WPB)-Fri./No. OLY-13/2 SUBPOENA FOR: PERSON b3 DOCUMENTS OR OBJECT[S] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: Fourth District Court of Appeals 1525 Palm Beach Lakes Boulevard West Palm Beach, Florida 33401 (Temporarilocation for the United States District Courthouse, West Palm Beach) ROOM: Courtroom DATE AND TIME: October 27, 2006 1:00pm YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): b3 Please coordinate your compliance with this subpoena and confirm the date and time of your appearance with Special Agent I Immigration and Customs Enforcement, Telephone: This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. b6 b7C DATE: October 19, 2006 This subpoena is issued upon application of the United States oEAmeica If not applicable, enter "none? Name, Address and Phone Number of Assistant U.S. Attorney Assistant U.S. Attorney 500 So. Australian Avenue, Suite 400 West Palm Beach, FL 33401-6235 Tel: Fax: To be used In lieu ofA0110 FORM ORD-R7s d3 3 1E- MN- / oro lee% 56?-4-2- EFTA01075218
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JAN.86 IP RETURN OF SERVICE, RECEIVED BY SERVER DATE 10/19/06 s. PLACE . USAO, West Palm Beach, FL SERVED DATE 10/19/06 RAC SERVED ON (NAME) • b3 1._ SERVED BY TIRE Special Agent, DHS/ICE . STATEMENT OF SERVICE FEES TRAVEL SERVICES TOTAL b6 b7C DECLARATION OF SERVICE2 I declare under penalty of penury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct. Executed on I 0 il 9 /2006 DATE glj 501 S. Flagler Dr., Ste. 500, WPB, FL 33401 Address of Server ADDITIONAL INFORMATION Served in person at 11:09 a.m. 1.As to who may servo a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2."Fees and mileage need not bo tendered to the witness upon service of a subpoena Issued onbehaif of the United States or an officer or agency thereof (Rule 45(c), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" lir EFTA01075219
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te hc States Districtturt SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 05-02(WPB)-Fri./No. OLY-10/2 b3 SUBPOENA FOR: n PERSON 11 DOCUMENTS OR OBJECT[S] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: Palm Beach County Courthouse Juvenile Courts Building 205 N. Dixie Highway West Palm Beach, Florida 33401 (Temporary location for the United States District Courthouse, West Palm Beach) ROOM: Room 4-A DATE AND TIME: September 15, 2006 9:00am YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): b3 Please coordinate your compliance of this subpoena and confirm the date and time of your appearance with Special Agents 'Federal Bureau of Investigation, Telephone:[ b6 . b7C Please see additional information on reverse This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. DATE: August 28, 2006 This subpoena is issued upon application of the United Statec of America in not applicable, enter "none.' Name, Address and Phone Number of Assistant U.S. Attorney !Assistant U.S. Attorney 500 So. Australian Avenue, Suite 400 West Palm Beach, FL 33401-6235 Tel Fax: To tc Wed le lieu Of AOI10 FORM ORD•227 ate- NM_ /0 V:162-6-s 24/ EFTA01075220
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JAN.86 • - RETURN OF SERVICE' • BY RECEIVED SERVER DAT0Eark sk PLACE W e8+7 01 44:P eestal it FL SERVED DATbikra/ 04 PLACE ada & oaf r Cc..:-.L. I SERVED ON (NAP/ b3 SERVED TITLE 4-1.28 I ....-3;?ecra iL b6 b7C STATEMENT OF SERVICE FEES TRAVEL SERVICES TOTAL DECLARATION OF SERVICE2 I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees true an correct. its Executed on UpriteG D E signature or server 9 '15- 5 A rr"Z -a3 — Address of Server ADDITIONAL INFORMATION 1.As to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2$Fees and mileage need not be tendered to tho witness upon service of a subpoena issued on behalf of the United States or an officer or agency thereof (Rule 45(c), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075221
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This subpoena is issued upon application of the United States of America_ 'S TO: United States District trurt SOUTHERN DISTRICT OF FLORIDA SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 05-02(WPB)-Fri./No. OLY-21 SUBPOENA FOR: PERSON 1,3 DOCUMENTS OR OBJECTS] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: United States District Courthouse 701 Clematis Street West Palm Beach, Florida 33401 ROOM: Grand Jury Room DATE AND TIME: December 1, 2006 9:30 am YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): Please coordinate your compliance with this subpoena and confirm the date and time of your appearance with Special Agent Federal Bureau of Investigation, Telephone: I This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. b3 b6 b7C DATE: November 13, 2006 Name, Address and Phone Number of Assistant U.S. Attorney assistant U.S. Attorney 500 So. Australian Avenue, Suite 400 West Palm Beach FL 39401-6235 Tel: Fax: *If not applicable, enter "none." To be used in tic. of A0110 3/5- qe4 /96-vb a-- al-P-2 e'r 4 FORM ORD-227 JAN.86 EFTA01075222
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S RETURN OF SERVICE' RECEIVED BY SERVER DATE / (172-0 (go PLACE ra k - Li -FR I --;__ SERVED DIAIT t7 / oh 7 PLACE Fre i - u TA ,Tz ra 1-3 I SERVED ON (NAME) b3 SERI TITLE 1 e_r__,cSi._ d j--B OF SERVICE FEES STATEMENT TRAVEL SERVICES b6 TOTAL 157e DECLARATION OF SERVICE' I declare Statement Executed under penalty of perjury under the laws of Service Fees Is true and correct. on UPI /Z° 0 4. of the United States of America that the foregoing information contained in the Return of Service and D TE Signalufa or aervur SOS- S. t to? -R 'Pi__ Address of Server f I ADDITIONAL INFORMATION 1.A3 to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2."Fees and mileage need not be tendered to the witness upon service of a subpoena Issued on behalf of the United States or an officer or agency thereof (Rule 45(c), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain Indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075223
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fitted States DistrictOourt SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 07-103(WPB)-Tues./No. OLY-37 SUBPOENA FOR: PERSON b3 DOCUMENTS OR OBJECT'S] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: United States District Courthouse 701 Clematis Street West Palm Beach, Florida 33401 ROOM: Grand Jury Room DATE AND TIME: March 27, 2007 1:00 pm* YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): *Please coordinate your compliance with this subpoena and confirm the date and time , and location of your appearance with Special Agent' 'Federal Bureau of Investigation, Telephone: This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. b3 136 b7C CLERK (BY) DEPUTY CLERK This subpoena is issued upon application of the United States of America DATE: March 16, 2007 / Name, Ad s and Phone Number of Assistant U.S. Attorney I 'Assistant U.S. Attorney 500 So. Australian Avenue, Suite 400 West Palm Beach, FL 33401-6235 Tax Fax: 9f not applicable, enter "none." To beaudio lieu of ACII 10 FORM ORD-227 JAN.86 4.saa 31 gpvvt - I o to 2_41411:3- EFTA01075224
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• RETURN OF SERVICE 0 RECEIVED BY SERVER DATE 3/14/07 PLACE We-s-i- R an, ge act., , CZ_ SERVED DATE3 40 PLACE tut t? /fl. ge4ce-- ,ca. SERVED ON (NAME) ( b3 TITLE Per 5- 4^ SERVED BY STATEMENT OF SERVICE FEES C TRAVEL SERVICES b6 TOTAL b7C DECLARATION OF SER VICE2 I declare under penalty of perjury under the lam of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct Executed on 0.740 7 DA Pr 57 4-apntoi 44, rizr....n-p "Pc Address of Server ADDITIONAL INFORMATION 1.As to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2."Fees and mileage need not be tendered to the witness upon service of a subpoena issued on behalf of the United States or an officer or agency thereof (Rule 45(c), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075225
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lited States Districttourt SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY • BEFORE GRAND JURY FGJ 07-103(WPB)-Tues./No. OLY-39 SUBPOENA FOR: • b3 PERSON DOCUMENTS OR OBJECT'S] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: United States District Courthouse 701 Clematis Street West Palm Beach, Florida 33401 ROOM: Grand Jury Room DATE AND TIME: April 3, 2007 1 :00pm* YOU ARE ALSO COMMANDED to bring with you the following document(s) or object(s): b3 *Please coordinate your compliance with this subpoena and confirm the date and time , and location of your appearance with Special Agent' I, Federal Bureau of Investigation, Telephone: This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. This subpoena is issued upon application of the United States of America b6 Name, Address and Phone Number of Assistant U.S. Attorney 'Assistant U.S. Attomey 500 So. Australian Avenue, Suite 400 West Palm Beach FL 33401-6235 Tel: Fax: II not applicable, enter none. To be ustd b Ike *MOM FORM ORD-227 JAN.86 3 Lc:-rnrn TN 67..: EFTA01075226
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• RETURN OF SERVICE, II RECEIVED BY SERVER - DATE O — 21 rl PLACE 1 ) IP ) 9_ I SERVED DATE* csi PLACE SERVED ON (NAME) b3 I SERVED BY % TITLE Th r /leas CA 4SCI- -NT\-- STATEMENT OF SERVI E FEES TRAVEL SERVICES TOTAL b6 b7C ' DECLARATION OF SERVICE I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct. Executed on 0 3 L dol DATE Signature C. r c>(. 5 -S . F 1 as(s reps( I\ re- ft Cc._ i Pk:55-2) Address of Server ADDITIONAL INFORMATION 1.As to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2."Fees and mileage need not be tendered to the witness upon service of a subpoena Issued on behalf of the United States or an officer or agency thereof (Rule 45(e), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain Indigent-parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075227
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• United States District Court SOUTHERN DISTRICT OF FLORIDA TO: SUBPOENA TO TESTIFY BEFORE GRAND JURY FGJ 07-103(WPB)-Tues./No. OLY-29 SUBPOENA FOR: • n PERSON b3 DOCUMENTS OR OBJECT[S] YOU ARE HEREBY COMMANDED to appear and testify before the Grand Jury of the United States District Court at the place, date and time specified below. PLACE: United States District Courthouse 701 Clematis Street West Palm Beach, Florida 33401 ROOM: Grand Jury Room DATE AND TIME: March 6, 2007 1:00 pm* YOU ARE ALSO COMMANDED to bring with you the following document(s) or objebt(s): See attachments *Please coordinate your compliance with this subpoena and confirm the date and time , and location of your appearance with Special Agents I Federal Bureau of Investigation, Telephone: This subpoena shall remain in effect until you are granted leave to depart by the court or by an officer acting on behalf of the court. (BY) DEPUTY CLERIC This subpoena is issued upon application of the United States of America a If not applicable, enter "none." DATE b6 b7C February 14, 2007 Name, Address and Phone Number of Assistant U.S. Attorney 'Assistant U.S. Attorney 500 So. Australian Avenue, Suite 400 West Palm Beach, FL 33401-6235 Tel: Fax: To be used urea of AO110 FORM ORD-227 JAN.86 31E- Ik4fri /0/060; at EFTA01075228
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• RETURN OF SERVICE, • RECEIVED BY SERVER DAT 420/01 PLACE t ops 1 SERVED DA6S/051 0 PLACE 6,/(/A fr A)C) SERVED ON (NAME b 3 SERVED B TITLE *F-B I 54 STATEMENT OF SERVICE FEES TRAVEL SERVICES b6 TOTAL b7C DECLARATION OF SERVICE2 I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained In the Return of Service and Statement of Service Fees Is true and correct. Executed on '3 5 (11 4 DA E • ST)S- - s. tviq_ey- , u?-8 fa I, Address of Server ADDITIONAL INFORMATION . . 1.As to who may serve a subpoena and the manner of its service see Rule 17(d). Federal Rules of Criminal Procedure, or Rule 45(c), Federal Rules of Civil Procedure. 2."Fees and mileage need not bo tendered to the witness upon service of a subpoena Issued on behalf of the United States or an officer or agency thereof (Rule 45(c), Federal Rules of Civil Procedure; Rule 17(d), Federal Rules of Criminal Procedure) or on behalf of certain indigent parties and criminal defendants who are unable to pay such costs (28 USC 1825, Rule 17(b) Federal Rules of Criminal Procedure)" EFTA01075229
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• • b3 ATTACHMENT TO GRAND JURY SUBPOENA FGJ 07-103 OLY-29 EFTA01075230
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U.S. Departn. of Justice United States Attorney Southern District of Florida 500 S. Australian Ave., Suite 400 West Palm Beach, FL 33401-6235 APPEARANCE NOTICE The attached subpoena requires the production of the records specified to a Federal Grand Jury/Trial in the Southern District of Florida. A new provision of the Federal Rules of Evidence provides that routine business records may be admitted at trial through the declaration of a custodian, if they are provided sufficiently in advance of trial to allow an opportunity for any challenges to their authenticity. Therefore, you may be able to avoid appearing personally at the grand jury/trial at the time and place specified by completely filling out the attached Certification and Inventory and immediately returning it with the records to Special Agent! FBI at the following address: Federal Bureau of Investigation 505 South Flagler Drive, Ste. 500 West Palm Beach, Florida 33401-5923 EARLY VOLUNTARY TURNOVER Please note that we are requesting an early voluntary turnover of the materials subpoenaed. The early voluntary turnover date is prior to March 6. 2007. BY: Sincerely, R. ALEXANDER ACOSTA UNITED STATES ATTORNEY ASSISTANT UNITED STATES ATTORNEY b6 b7C EFTA01075231
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CERTIFICATION OF BUSINESS RECORDS I, the undersigned, , declare that I am: employed by/associated with in the position of and by reason of my position am authorized and qualified to make this declaration. In my employment with the above-named bank/company I am familiar with the business records it maintains. The above-named bank/company maintains records of its business which are: 1. made at or near the time of the occurrence of the matters set forth therein, by, or from information transmitted by, a person with knowledge of those matters; 2. kept in the course of regularly conducted business activity; and 3. made by the regularly conducted activity as a regular practice. Among the records so maintained are the attached records itemized in Appendix A, Inventory of Documents. I declare under penalty of perjury that the foregoing is true and correct. Date of execution: Place of execution: Signature: EFTA01075232
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• APPENDIX A • DOCUMENT INVENTORY The documents submitted are as follows: Signature of Records Custodian: EFTA01075233
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'Washington, D.C. 20530 U.S. Department of Justice Request for Financial Information (Authorization, Purchase Order, Receiving Report) This form shall only be toed when removing fluvial records of individuals ad parmersbips 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-29 4 Name and Address of Financial Institution. 5 Deliver To: FBI Special Agent) Section A - Authorization and Purchase Order 6 Return Date: 3/6/2007 7 Itewanks: FOR REIMBURSEMENT PLEASE RETURN THIS FORM, THE RECORD OF SERVICES, AND A COPY OF THE SUBPOENA. 8 Name of Roauestor mine or Prim) AUSAI i 9 TelerrhoncNomher l 10 Date of request: 2/14/2007 Section B - Financial Institution Invoice No Payment Shall Be Made Unless Expenses Me Itemized Below Or On Your Form ToBe Attached. II Senriee/Firtandal Records Provided: Quantity Unit Price Amount Cost Per FOR PROMPT PAYMENT INCLUDE TAX I.D. 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 $500 without prior approval of 0.25 11.00 17.00 Copy Hour Clerical Tech Hour Manger or Supervisor Budget Office.' "Fax any request to (305)530.7679 12 Signature of Financial Institution Official: 13 Date Signed: Total AmountClaimed By Financial Institution 0.00 Section C - Receiving Report 16 Disallowance art Attached) 14 I certify that the articles and semi= listed were received: 15 Date Received: 17 Net to Financial Institution III Right to Financial (12 U.S.C.3401-3422)Request SECTION o o In • • II ■ Privacy Act - Public Law 95-630 Pursuant To: (Check One Only) OBJECT CLASS 3404 Customer Authorization 2540 3405 Administrative Subpoena or Summons 2541 3406 Search Warrant 2542 3407 Judicial Subpoma 2543 3408 Formal Written Request 2544 3413 I Grand Jury Subpoena 2545 3414 Special Procedures 2546 19 Signature of Approving Official: 20 Accounting Classification Code FY FCI I 2 3 4 5 PROJ I I 1 . 1 11 I I 21 &attic aad YoucherNumbet Dal 22 Re:mks: 0 Funds Available Date: Budget Officer: This form was ontroninsiv PC411Otid bf Elio Federal Form. Inc 0 FORM OBD-2 I I APR BO b3 156 b7C EFTA01075234
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• GENERAL This is a mul ti.purpose form designed to sent as an Authorization, Purchase Oder, Itemized Invoice, ReceivjggRepon and Payment voucher in conjunction with "requests for financial information,' pursuant to the Right toFinancial Privacy Act of 1978, 95.630, Tide 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 n proper InvoiceIn the office designated to receive the invoice the date of the check issued in payment shall be considered to be the dale payment is made. The Prompt Payment Act, Public Law 97-177,96 Stat 85 (31 U.S.0 180), 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 provaions of the Prompt Payment Act and the Office of Management and Budget Circular A-125. PREPARATION INSTRUCTIONS ITEM I -A Purchase Order Number will be preprinted on each form This number will be used for reference purposes on any correspondence relating to this sped fic request for Muncie! information. • ITEM 2 - Self explanatory. ITEM 3 - This blodc may be used to identify the specific case for which the ftruncial information is required. This blodc may be left blank. SECTION A -AUTHORIZATION AND PURCHASE ORDER (To be completed by the requesangofficial). ITEM 4 - Enter the name and mailing address of the financial institution behgrequested to furnish fmancial infomutien. 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 add =sof the requesting official. ITEM 6 - Enter the date the financial information is required. ITEM 7 - Include, if appropriae, any pertinent information related to the punhase order not provided for elmwhere on the form. ITEM 8,9 and 10 - Sdf-explanatory. SECTION - FINANCIAL INSTITUTION INVOICE (To be completed by the financial indiction). ITEM II - Self-explanatory. Completion of this block constitutes an itemized till or invoice for reimbursement for the cons incurred in providing the infomation requested. ITEM 12 end 13 - Self-explanatory. SECTION C - RECEIVING REPORT (To be completed by the requesting official, whenthe requested financial information has been delivered). ITEM 14 and I5 Self-explanatory. ITEM 16 - This block should be used to reflect any differences between the anion claimed by the financial instkution and the correct amount to be reimbursed Differences may result from computation arms, or failure of the financial inlitudon 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 ty the Act, which necessitates the request for financial infarmation. • ITEM 19 and 20 -These blocks must be signed and dated by an official of the oganization whose finds will be charged. His or her signature consitutes a staement that the records to which the invoice refers were required for official business and were provided by the-financial institution in xcordance with the ordering instnment ITEM 2I - The Schedule and Voucher Number will be entered by the office which lewdly schedules the approved amount for payment by the Treasury DepartMent. ITEM 22 - Enter, if appropriate, my data not provided for elsewhere on the rettiving report, such as, reasons for any claim amounts disalbwed. EFTA01075235