Form 104 - Currency Transaction Report Form

Page 4

FinCEN Form 104 (Formerly 4789 (Rev. 8-03)

Item 36. Other (specify). If a transaction is not identified

However, there may be instances in which Items 15-25

If there is a currency exchange, it should be aggregated

in Items 30-34, check Item 36 and provide an additional

may be left BLANK or incomplete. If Items 15-25 are

separately with each of the Cash In and Cash Out totals.

description. For example, a person presents a check to

left BLANK or incomplete, check one or more of the

purchase “foreign currency.” Also list multiple foreign

boxes provided to indicate the reasons.

Example 1: A person deposits $11,000 in currency to

currencies from item 29.

his savings account and withdraws $3,000 in currency

Example: If there are multiple transactions that, if only

from his checking account. The CTR should be

PART III - Financial Institution Where Transaction(s) Take

when aggregated, the financial institution has knowledge

completed as follows:

Place

the transactions exceed the reporting threshold, and

Cash In $11,000 and no entry for Cash Out. This is

therefore, did not identify the transactor(s), check box d

because the $3,000 transaction does not meet the

Item 37. Name of Financial Institution and Identity of

for Multiple Transactions.

reporting threshold.

Regulator or BSA Examiner. Enter the financial institution’s

full legal name and identify the regulator or BSA examiner,

Items 15, 16, and 17. Individual’s Name. Complete

Example 2: A person deposits $11,000 in currency to

using the following codes:

these items if an individual conducts a transaction(s) on

his savings account and withdraws $12,000 in currency

behalf of another person. For example, if John Doe, an

from his checking account. The CTR should be

Regulator or BSA Examiner

CODE

employee of XYZ Grocery Store, makes a deposit to the

completed as follows:

Comptroller of the Currency (OCC).........................1

store’s account, XYZ Grocery Store should be identified

Cash In $11,000, Cash Out $12,000. This is because

Federal Deposit Insurance Corporation (FDIC)........2

in Section A and John Doe should be identified in section

there are two reportable transactions. However, one

Federal Reserve System (FRS)...........................................3

CTR may be filed to reflect both.

Office of Thrift Supervision (OTS)......................................4

National Credit Union Administration (NCUA)........5

Items 18, 20, 21, 22, and 23. Address. Enter the

Example 3: A person deposits $6,000 in currency to his

Securities and Exchange Commission (SEC).............6

permanent street address including ZIP Code of the

savings account and withdraws $4,000 in currency from

Internal Revenue Service (IRS).........................................7

individual. (See the instructions for Items 7 and 9 through

his checking account. Further, he presents $5,000 in

U.S. Postal Service (USPS).................................................8

Commodity Futures Trading Commission (CFTC)...............9

12.) Enter country code if not U.S. (Reference item 12).

currency to be exchanged for the equivalent in French

State Regulator.................................................................10

Francs. The CTR should be completed as follows:

Item 19. SSN/ITIN. If the individual has a Social Security

Cash In $11,000 and no entry for Cash Out. This is

Items 38, 40, 41, and 42. Address. Enter the street address,

Number, or Individual Taxpayer Indentifcation Number,

because in determining whether the transactions are

city, state, and ZIP Code of the financial institution where

enter it in Item 19. If the individual does not have an

reportable, the currency exchange is aggregated with

the transaction occurred. If there are multiple transactions,

SSN/ITIN, enter NONE.

each of the Cash In and Cash Out amounts. The result is

provide information of the office or branch where any one

a reportable $11,000 Cash In transaction. The total Cash

of the transactions has occurred.

Item 24. Date of Birth. Enter the individual’s date of

Out amount is $9,000, which does not meet the

birth. (See the instructions for Item 8.)

reporting threshold. Therefore, it is not entered on the

Item 39. EIN or SSN. Enter the financial institution’s EIN.

CTR.

If the financial institution does not have an EIN, enter the

Item 25. If an Individual, Describe Method Used To

SSN of the financial institution’s principal owner.

Verify Identify. Enter the method used to identify the

Example 4: A person deposits $6,000 in currency to his

individual’s identy. (See General Instructions and the

savings account and withdraws $7,000 in currency from

Item 43. Routing (MICR) Number. If a depository

instructions for Item 14.)

his checking account. Further, he presents $5,000 in

institution, enter the routing (Magnetic Ink Character

currency to be exchanged for the equivalent in French

Recognition (MICR)) number.

PART II - Amount and Type of Transaction(s)

francs. The CTR should be completed as follows:

Complete Part II to identify the type of transaction(s)

Cash In $11,000, Cash Out $12,000. This is because

SIGNATURE

and the amount(s) involved.

in determining whether the transactions are reportable,

the currency exchange is aggregated with each of the

Items 44 and 45. Title and signature of Approving

Items 26 and 27. Total Cash In/Total Cash Out. In the

Cash In and Cash Out amounts. In this example, each

Official. The official who reviews and approves the CTR

spaces provided, enter the total amount of currency

of the Cash In and Cash Out totals exceed $10,000 and

must indicate his/her title and sign the CTR.

received (Total Cash In) or total currency disbursed (Total

must be reflected on the CTR.

Item 46. Date of Signature. The approving official must

Cash Out) by the financial institution. If foreign currency

enter the date the CTR is signed. (See the instructions for

is exchanged, use the U.S. dollar equivalent on the day

Items 30-33. Check the appropriate item(s) to identify

Item 8.)

of the transaction (See “Foreign exchange rates”), and

the following type of transaction(s):

complete item 26a or 27a, whichever is appropriate.

30. Wire Transfer(s)

Item 47. Preparer’s Name. Type or print the full name of

31. Negotiable Instrument(s) Purchased

the individual preparing the CTR. The preparer and the

If less than a full dollar amount is involved, increase

32. Negotiable Instrument(s) Cashed

approving official may not necessarily be the same

that figure to the next highest dollar. For example, if the

33. Currency Exchange(s)

individual.

currency totals $20,000.05, show the total as

$20,001.00.

Item 34. Deposits/Withdrawals. Check this item to

Items 48 and 49. Contact Person/Telephone Number.

identify deposits to or withdrawals from accounts, e.g.

Type or print the name and telephone number of an

Items 26a and 27a. Foreign cash in/Foreign cash out.

demand deposit accounts, savings accounts, time

individual to contact concerning questions about the CTR.

If foreign currency is exchanged, enter the amount of

deposits, mutual fund accounts, or any other account

foreign currency in items 26a and 27a. Report country

held at the financial institution. Enter the account

Paperwork Reduction Act Notice. The requested

of origin in item 29.

number(s) in Item 35.

information is useful in criminal, tax, and regulatory

investigations and proceedings. Financial institutions are

Item 28. Date of Transaction. Insert eight numerals for

Item 35. Account Numbers Affected (if any). Enter

required to provide the information under 31 U.S.C.

each date. (See instructions for Item 8.)

the account numbers of any accounts affected by the

5313 and 31 CFR Part 103, commonly referred to as the

transactions that are maintained at the financial

Bank Secrecy Act (BSA). The BSA is administered by the

Item 29. Foreign Currency. If items 26a and/or 27a are

institution conducting the transaction(s). If necessary,

U.S. Department of the Treasury’s Financial Crimes

completed indicating that foreign currency is involved,

use additional sheets of paper to indicate all of the

Enforcement Network (FinCEN). You are not required

check Item 29 and identify the country. If multiple

affected accounts.

to provide the requested information unless a form

foreign currencies are involved, check box 36 and

displays a valid OMB control number.

identify the additional country(s) and/or currency(s)

Example 1: If a person cashes a check drawn on an

The time needed to complete this form will vary

involved.

account held at the financial institution, the CTR should

depending on individual circumstances. The estimated

be completed as follows:

average time is 19 minutes. If you have comments

Determining Whether Transactions Meet the

Indicate negotiable instrument(s) cashed and provide

concerning the accuracy of this time estimate or

the account number of the check.

Reporting Threshold.

suggestions for making this form simpler, you may write

to the Financial Crimes Enforcement Network, P. O.

If the transaction does not affect an account, make no

Only cash transactions that, if alone or when

Box 39, Vienna, VA 22183. Do not send this form to

entry.

aggregated, exceed $10,000 should be reported on the

this office. Instead, see When and Where to File in the

CTR. Transactions shall not be offset against one another.

instructions.

Example 2: A person cashes a check drawn on another

financial institution. In this instance, negotiable

If there are both Cash In and Cash Out transactions

instrument(s) cashed would be indicated, but no account

that are reportable, the amounts should be considered

at the financial institution has been affected. Therefore,

separately and not aggregated. However, they may be

Item 35 should be left BLANK.

reported on a single CTR.

Form 104 - Currency Transaction Report Form - 2003 Page 4

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