EFTA00619489.pdf

TAX RETURN FILING INSTRUCTIONS REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS DECEMBER 31, 2014 Prepared for Prepared by Form must be filed on or before Special Instructions THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC RAICH ENDE MALTER & CO., LLP JUNE 30, 2015 FORM 114 HAS BEEN PREPARED FOR ELECTRONIC FILING. PLEASE SIGN, DATE, AND RETURN FORM 114A TO OUR OFFICE. WE WILL THEN TRANSMIT YOUR REPORT TO THE FINCEN. 420397 0:3114 EFTA00619489 FINANCIAL CRIMES ENFORCEMENT NETWORK BSA E-Filing - Report of Foreign Bank and Financial Accounts (FBAR) THEBLAC20140001 Filing Name THE BLACK FAMILY 1997 TRUST Submission Type NEW PIN NOT REQUIRED Version Number: El FinCEN Form 114 OMB Control Number: 1506.0009 Effective January', 2014 Check here if this report is submitted by an authorized third party, and complete the 3rd party preparer section on page one of the report. The E-file system will auto complete item 46. NOTE: The FBAR must be received by the Department of the Treasury on or before June 30th of the year immediately following the calendar year being reported. The June 30th filing date may not be extended. This report filed late for the following reason (Check only one): a P Forgot to file b g O Did not know that I had to file Thought account balance was below reporting threshold Did not know that my account qualified as foreign e 0 Account statement not received in time 0 Account statement lost (Replacement requested) Late receiving missing required account information Unable to obtain joint spouse signature in time Unable to access BSA Efiling system Other (please provide explanation below) 423151 05-01.M EFTA00619490 Form 114a Department of the Treasury Financial Crimes Enforcement Network (FinCEN) October 2013 Record of Authorization to Electronically File FBARs (See instructions below for completion) Do not send to FinCEN. Retain this form for your records. THEBLAC20140001 Part I I Persons who have an obligation to file a Report of Foreign Bank and Financial Account(s) • Owner last name or entity's legal name THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC 2. Owner first name I. Owne' 4. Spouse last name of jointly filing FBAR • see instructions below) 5. Spouse first name 6. Spouse Vwe declare that Vwe have provided information concerning 16 (enter number of accounts) foreign bank and financial account(s) for the filing year ending December 31. 2 014 to the preparer listed in Part II; that this information is to the best of my/our knowledge true, correct, and complete; that I/we authorize the preparer listed in Part II to complete and submit to the Financial Crimes Enforcement Network (FinCEN) a Report of Foreign Bank and Financial Accounts (FBAR) based on the information that Vwe have provided: and that Vwe authorize the preparer listed in Part II to receive information from FinCEN. answer inquiries and resolve issues relating to this submission. Vwe acknowledge that, notwithstanding this declaration, it is my/our legal responsibility, not that of the preparer listed in Part II, to timely file an FBAR if required by law to do so. 7. Owner signature (Authorized representative if entity) 8. Date 9. Owner or entity TIN 137314635 10. TIN a ON type b SSNATiN c Foreign MM DD rnne 11. Spouse signature 12. Date 13. Spouse TIN 14. TIN a I ION type b O SSNATIN c Foreign MM DD YYYY Part II I Individual or Entity Authorized to File FBAR on behalf of Persons who have an obligation to file. 15. Preparer last name TURRIN 16. Preparer first name HOMAS 17. Prepare( 18. Preparer PTIN P00850244 19. Address 20. City 21. State 22. ZIP/postal code 23. Country code US 24. Preparer's (item 15) employer's (En ity) name RAICH ENDE MALTER & CO., LLP 25. Employer EIN 11-2336434 26. Preparer's ignature Instructions for completing the FBAR S gnature Authorization Record This record may be completed by the individual or entity granting such authorization (Part I) OR the individuaVentity authorized to perform such services. The completed record must be signed by the individual(syentity grant ng the authorization (Part I) and the individuaVentity that will file the FBAR. The Preparer/filing entity must be registered with FinCEN BSA E•File system. (See http://bsaefiling.fincentreas.gov/main.html for registration). Read and complete the account owner statement in Part I. To authorize a third party to file the Foreign Bank and Financial Accounts Report (FBAR), the account owner should complete Past I, items I through I (as required), sign and date the document in Part I. items 7/8 and complete items 9 and 10. Accounts Jointly Owned by Spouses (see exceptions in the FBAR instructions) If the account owner is filing an FBAR jointly with his/her spouse, the spouse must also complete Part I, items 4 through 6. The spouse must also sign and date the report in items 11/12. and complete items 13 and 14. A third party preparer may be one of the spouses of the jointly owned foreign account. In this case, both spouses must complete Part I of form 114a in its entirety. The third party preparer (spouse) that will file the FBAR on behalf of both spouses will complete Part II in its entirety (do not use such terms as see above, or same as item number M. Complete Part II. items 15 through 18 with the preparer's information. The address, items 19 through 23. is that of the preparer or the preparer's employer if the preparer is an employee. Record the employer's information (if any) in items 24 and 25. If the preparer does not have a PTIN. leave item 18 blank The third party preparer must sign in item 26 of Part II indicating that the FBAR will be filed as directed by the authorizing authority. The person(s) listed in Part I, and the person listed in Part II as authorized to file on behalf of the person(s) listed in Part I. should retain copies of this record of authorization and the filing itself, both for a period of 5 years. See 31 CFR 1010.430(d). DO NOT SEND THIS RECORD TO FinCEN UNLESS REQUESTED TO DO SO. Rev. 10.4 July 11.2O13 EFTA00619491 FinCEN Form 114 Doparnnomoltno Trnowy OMB no. 1506-0009 Pot Soptomtor 2013) I Part I I Filer information 2 Type of filer REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS Do NOT file with your Federal Tax Return Do not use previous editions of this form THEBLAC20140001 I This report is for calendar year ended 12/31 2014 Ame n a 0 Individual b Partnership c 0 Corporation d Consolidated e Fiduciary or other • Enter type I U.S. Taxpayer Identification Num 3a TIN type 4 Foreign identification (Complete only if item I is not applicable) 5 Individual's date of birth MWDD/YYYY SSNATIN a Type' Foreign TIN Other 137314635 If filer has no U S Identification Passport ILI al BN number complete item 4 b Number c Country of Issue 6 Last name or organization name 7First name 8 Middle initial 8a Suffix THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC 9 Mailing address (number. street. and apt. or suite no.) 10 City 11 State U 12 ZIP/Postal Code 13 Country SA 14 a) Does the filer have a financial interest in 25 or more financial accounts? Yes 0 Enter number of accounts Do not complete Part II or Part III, but maintain records of the information. No IM b) Does the filer have signature authority over but no financial interest in 25 or more financial accounts? Yes 0 Enter number of accounts Comp. Part IV, items 34 through 43 for each person on whose behalf the filer has sign. authority. No I Part III information on financial account(s) owned separately 15 Maximum value of account during calendar year 15a Amount unknown 16 Type of account aLXJ Bank bU Securities cLJ Other • Enter type below 4,904,996. 17 Name of financial institution in which account is held BANK OF SCOTLAND 18 Account number or other designation 19 Mating address (number, street. apt. or suite no.) of financial institution in which account is held 00152847 THE MOUND 20 City 21 State. if known 22 Foreign postal code, if known 23 Country EDINBURGH EH11YZ UNITED KINGDOM I-Signature-I 44a Check here LXJ if his report is completed b a third party preparer and complete the third Party preparer section. 44 Filor signature 1N report wJl Do electronically Mongol ninon NO 45 Filer title, if not reporting a personal account Third Party Preparer Use Only 47 Preparer's last name TURRIN 52 Contact phone no. 212-944-4433 46 Date (MM/D mecistowjinao nt ritno 48 First name 49 MI 50 Checks I if 51 TIN THOMAS serf employed? 00850244 52a Ext. -IE: A 3 Firm's name 54 Finn's TIN ICH ENDE MALTER & 11-2336434 FBAil Ia ektictronnsignoti 51a TIN type PTIN SSN/ITIN 0 Foreign 54a TIN type LXJ EIN Foreign 55 Mailing address (number. street, apt. or suite no. 56 Cif yi tate 58 ZIP/Postal Code 59 Country US This form should be used to report a financial interest in, signature authority, or other authority over one or more financial accounts in foreign countries, as required by the Department of the Treasury Regulations 31 CFR 1010.350. No report is required if the aggregate value of the accounts did not exceed $10,000. See inst uctions for definitions. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on FinCEN Form 114 in accordance with 5 USC 552a (e) is Public Law 91-508; 31 USC 5314; 5 USC 301' 31 CFR 1010.350. The principal purpose for collecting the information is to assure maintenance of reports where such reports or records have a high degree of usefulness in criminal, tax, or regulatory investigations or proceedings. The information collected may be provided to those officers and employees of any constituent unit of the Department of the Treasury who have a need for the records in the performance of their duties. The records may be referred to any other department or agency of the United States upon the request of the head of such department or agency for use in a criminal, tax, or regulatory investigation or proceeding. The information collected may also be provided to appropriate state, local, and foreign law enforcement and regulatory personnel in the performance of their official duties. Disclosure of this information is mandatory. Civil and criminal penalties, including in certain circumstances a fine of not more than $500,000 and imprisonment of not more than five years, are provided for failure to file a report, for failure to supply information, and for filing a false or fraudulent report Disclosure of the Social Security number is mandatory. The authority to collect is 31 CFR 1010.350. The Social Security number will be used as a means to identify the individual who files the report. The estimated average burden associated with this collection of information is 60 minutes per respondent or record keeper, depending on individual circumstances. Comments regarding the accuracy of this burden estimate, and suggestions for reducing the burden should be directed to the Financial Crimes Enforcement Network, • Box 39, Vienna, VA 22183, Attn: Office of Regulatory Policy. 425141 05-01.14 Rev 5.7 • 6112013 EFTA00619492 !Partin Continued - Information on Financial Account(s) Owned Separately Complete a Separate Block for Each Account Owned Separately FORM 114 Page Number 2 of 4 I Filing for calendar year 2014 .4 Check appropriate Identification Number Taxpayer Identification Number ILI Foreign Identification Number Enter identification number here: 137314635 6 Last Name or Organization Name THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC 15 Maximum value of account during calendar year 1,568,777. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 755 AmmadUnkoown U 16 Type of account a I X I Bank b I I Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 15 Maximum value of account during calendar year 686,766. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 22 ZIP,Postal Code, if known 23 Country EH11YZ UNITED KINGDOM 15a Amount Unknown 16 Type of account a LIJ Bank b U Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 15 Maximum value of account during calendar year 365,389. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 22 ZIPipostal Code, if known 23 Country EH11YZ UNITED KINGDOM 15a Amount Unknown O 16 Type of account a LIJ Bank b U Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 15 Maximum value of account during calendar year 2,508. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 22 ZIPipostal Code, if known 23 Country EH11YZ UNITED KINGDOM 15a Amount Unknown O 16 Type of account a LIJ Bank b U Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 15 Maximum value of account during calendar year 217,523. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 22 ZIPipostal Code, if known 23 Country EH11YZ UNITED KINGDOM 15a Amount Unknown O 16 Type of account a LIJ Bank b U Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 15 Maximum value of account during calendar year 83,397. 17 Name of Financial Institution in which account is h Id BANK OF SCOTLAND 18 Account number or other designation 22 ZIPipostal Code, if known 23 Country EH11YZ UNITED KINGDOM 15a Amount Unknown O 16 Type of account a LxJ Bank b U Securities e I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State. if known 20 City EDINBURGH 22 ZIP/Postal Code, if known EH11YZ 23 Country UNITED KINGDOM 420015 05.0111 EFTA00619493 I Part III Continued - Information on Financial Account(s) Owned Separately Complete a Separate Block for Each Account Owned Separately FORM 114 Pa Number of 4 I Filing for calendar year 2014 ut Check appropriate Identification Numbe Taxpayer Identification Number Foreign Identification Number Enter identification number here: 137314635 6 Last Name or Organization Name THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC 16 Maximum value of account during calendar year isa Amount unknown 37,423. 18 Type of account a Bank b Securities C U Other - Enter type below 17 Name of Financial Institution in which account is held BANK OF SCOTLAND 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held THE MOUND 21 State, if known 20 City EDINBURGH 16 Maximum value of account during calendar year 1,375. 17 Name of Financial Institution in which account is h Id LA CAIXA 18 Account number or other designation 22 ZIP/Postal Code, it known 23 Country EH1 lYZ UNITED KINGDOM 15a Amount Unknown 18 Type of account a LXJ Bank b U Securities c — Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held DIAGONAL-CARIES III, AV DIAGONAL 621-629 20 City 21 State, if known BARCELONA 16 Maximum value of account during calendar year isa Anoint Unknown 193,468. 22 ZIP/Postal Code, it known 08028 18 Type of account a Bank b 23 County SPAIN Securities c Other - Enter type below 17 Name of Financial Institution in which account is held COMMERZBANK AG 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 16 KAISERSTRASSE 20 City 21 State, if known FRANKFURT 16 Maximum value of account during calendar year isa Anoint Unknown 705,634. 22 ZIP/Postal Code, it known AMMA IN 8 Type of account a Bank b 23 Country GERMANY Securities c Other - Enter type below 17 Name of Financial Institution in which account is held SOCIETE GENERALE 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held BERCY ENTR 10 AVENUE LEDRU ROLLIN 20 City 21 State, if known PARIS 16 Maximum value of account during calendar year isa Anoint Unknown 39,489. 22 ZIP/Postal Code, it known 75012 18 Type of account a Bank b 23 County FRANCE Securities c Other - Enter type below 17 Name of Financial Institution in which account is held COMMONWEALTH BANK OF AUSTRALIA 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 48 MARTIN PL 20 City 21 State, if known SYDNEY 16 Maximum value of account during calendar year isa Amara Unknown 34,851. 22 ZIP/Postal Code, it known NSW2000 18 Type of account a Bank b 23 County AUSTRALIA Securities c Other - Enter type below 17 Name of Financial Institution in which accoun is held BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 2137270 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City 21 State, if known 22 ZIP/Postal Code, it known 23 County TOKYO 1710021 JAPAN 420015 05-01-14 EFTA00619494 Part III Continued - Information on Financial Account(s) Owned Separately Complete a Separate Block for Each Account Owned Separately FORM 114 Page Number 4 of 4 I Filing for calendar year 2014 I-4 Check appropriate Identification Number Taxpayer Identification Number Foreign Identification Number Enter identification number here: 137314635 6 Last Name or Organization Name THE BLACK FAMILY 1997 TRUST C/O ELYSIUM MANAGEMENT LLC 15 Maximum value of account during calendar year 2. 17 Name of Financial Institution in which account is h Id BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City TOKYO 21 State. it known 22 ZIP,Postal Code, if known 1710021 23 Country JAPAN 15 Maximum value of account during calendar year 15a AcI3Oull 110kraDvon 16 43,240. I Type of account a I X I Bank b Securities e LJ Other -Enter type below 17 Name of Financial Institution in which account is h Id BANK OF TOKYO-MITSUBISHI UFJ L 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 1-22-8 NISHI-IKEBUKURO TOSHIMA-KU 20 City TOKYO 21 State. it known 22 ZIP,Postal Code, if known 1710021 23 Country JAPAN 15 Maximum value of account during calendar year 15a Af1304,01 Unknown 16 Type of account a LIJ Bank b Securities 53,574. I c LJ Other -Enter type below 17 Name of Financial Institution in which account is h Id CREDIT SUISSE AG 18 Account number or other designation 15a Amouit Unknown 16 Type of account a I X I Bank b I I Securities c I I Other - Enter type below 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held POSTFACH 357, 21 State. if known 20 City ZUG 15 Maximum value of account during calendar year 22 ZIP/Postal Code, if known 23 Country 6301 SWITZERLAND 15a Af1304,01 Unknown 16 Type of account a LJ Bank b LI Securities c L I Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 20 City 21 State. it known 15 Maximum value of account during calendar year 15a Af1304,01 Unknown I L j 22 ZIP/Postal Code, if known 23 Country 16 Type of account a LJ Bank b Securities cL Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 20 City 21 State. it known 15 Maximum value of account during calendar year 15a Af1304,01 Unknown I L j 22 ZIP/Postal Code, if known 23 Country 16 Type of account a LJ Bank b Securities c L Other -Enter type below 17 Name of Financial Institution in which account is h Id 18 Account number or other designation 19 Mailing Address (Number, Street, Suite Number) of financial institution in which account is held 20 City 21 State. if known 22 ZIP/Postal Code, if known 23 Country 420015 05-01.14 EFTA00619495