Sample Filled-Out Form 8300 Page 2
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1
2
3IRS
Form
8300
(Rev. August 2014)
Report of Cash Payments Over $10,000
Received in a Trade or Business
~See
instructions for definition of cash.
(Rev. August
2014
)
~Use
this form for transactions occurring after August 29, 2014. Do not use prior versions after this date. OMB
No.
1506
-
0018
Department of the Treasury
Department of the Treasury
Internal Revenue Service
For Privacy Act and Paperwork Reduction Act Notice, see the last page.
~~f~~g~':i,~~~mtf:twork
Check appropriate box(es) if:
a
D
Amends prior report;
b
0
Suspicious transaction.
ldll
Identity of Individual From Whom the Cash Was Received
2
If more than one individual is involved, check here and see instructions .
3
Last riame
4 First name
SMITH
JANE
7
Address (number, street, and apt. or suite no.)
7 MAIN STREET
5 M.1.
J
8 Date of birth .
(see instructions)
-~D
6 Taxpayer identification number
~
M
M
D
D
Y
Y
Y
Y
o:
0:1
1:9:7:0
9
City
10 State
11 ZIP code
12 Country (if not U.S.)
13 Occupation, profession, or business
RESTAURANT OWNER
ANYWHERE
C
l
T
06000
14
Identifying
a Describe
ID~
DRIVERS LICENSE
b Issued
by~
CONNECTICUT
document
(ID)
c Number..,..
------------------------------2i45-6789_0 _____________________________ _
Person on Whose Behalf This Transaction Was Conducted
15
If this transaction was conducted on behalf of more than one person, check here and see instructions
-~D
16
Individual's last name or organization's name
17 First name
18
M.1.
19 Taxpayer identification number
SMITH
20
Doing business as (DBA) name (see instructions)
21
Address (number, street, and apt. or suite no.)
7 MAIN STREET
JOSEPH
J
Employer identification number
22 Occupation, profession, or business
STUDENT
23
City
24 State
25 ZIP code
26 Country (if not U.S.)
ANYWHERE
27
Alien
a Describe ID
~
identification {ID) c
Number~
C l T
06000
b Issued
by~
Description of Transaction and Method of Payment
28
Date cash received
29 Total cash received
30
If cash was received in
more than one payment,
check here
.
.
~
31 Total price if different from
item 29
M M D D Y Y Y Y
0: 9
0 : 1
$
11,000.00
D
$
1s,ooo.oo
32
Amount of cash received (in U.S. dollar equivalent) (must equal item 29) (see instructions):
a
U.S. currency
$
11,000
.DO
(Amount in $100 bills or higher$
11,000.00)
b
Foreign currency
$
.OD
(Country~
_ _ _ _ _ _ _ _ _
~~~§~;:~:~) ~
•!! )
;"''';'iaj~~'"''':"":~':"(aj:;f:th:':~':"='~'''"m,:•l:l;
: : : : : : : : : : : : : :
c
d
e
33
Type of transaction
a
D
Personal property purchased
D
b
D
Real property purchased
g
D
c
D
Personal services provided
h
D
d
D
Business services provided
D
e
D
Intangible property purchased
j
0
l::,P.T~~H'.I
Business That Received Cash
35
Name of business that received cash
YALE UNIVERSITY
37
Address (number, street, and apt. or suite no.)
246 CHURCH STREET
Debt obligations paid
Exchange of cash
Escrow or trust funds
Bail received by court clerks
Other (specify in item 34)
~
34 Specific description of property or service shown in
33. Give serial or registration number, address, docket
number, etc.
~
TUITION, ROOM, BOARD AND
----------------------------------------------
FE ES - FALL SEMESTER 2014
EDUCATIONAL SERVICES
36 Employer identification number
0:6!0:6:4:6:9:1:3
Social security number
I
I
38
City
139 State 140 ZIP code
141 Nature of your business
NEW HAVEN
C
l
T
06510
EDUCATION
42
Under penalties of perjury, I declare that to the best of my knowledge the information I have furnished above is true, correct,
and complete.
Signature
43 Date of
signature
M
M
IRS Form
8300
(Rev. 8-2014)
Title
~
Cat. No. 621338
DIRECTOR OF STUDENT ACCOUNTS
45 Contact telephone number
203-432-0000
FinCEN Form
8300
(Rev. 8-2014)
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