Irs Publication 1544 - Reporting Cash Payments - 2012 Page 6
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68300
8300
Report of Cash Payments Over $10,000
IRS
FinCEN
Received in a Trade or Business
Form
Form
(Rev. July 2012)
(Rev. July 2012)
See instructions for definition of cash.
OMB No. 1506-0018
OMB No. 1545-0892
Use this form for transactions occurring after July 8, 2012. Do not use prior versions after this date.
Department of the Treasury
Department of the Treasury
Financial Crimes
For Privacy Act and Paperwork Reduction Act Notice, see the last page.
Internal Revenue Service
Enforcement Network
1
Check appropriate box(es) if:
a
b
Amends prior report;
Suspicious transaction.
Part I
Identity of Individual From Whom the Cash Was Received
2
If more than one individual is involved, check here and see instructions .
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3
Last name
4 First name
5 M.I.
6 Taxpayer identi cation number
Smith
Jane
A
3 3
3
3 3 3 3
0
0
8 Date of birth .
.
.
7
Address (number, street, and apt. or suite no.)
M
M
D
D
Y
Y
Y
Y
(see instructions)
1 0 0 6 1 9 6 3
100 Main Street
9
City
10 State
11 ZIP code
12 Country (if not U.S.)
13 Occupation, profession, or business
P
A
Hometown
10101
Cosmetic Distributor
14
Identifying
a Describe ID
b Issued by
Driver’ s License
document (ID)
c Number
333-00-3333
PA
Part II
Person on Whose Behalf This Transaction Was Conducted
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If this transaction was conducted on behalf of more than one person, check here and see instructions .
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16
Individual’s last name or organization’s name
17 First name
18 M.I.
19 Taxpayer identi cation number
20
Doing business as (DBA) name (see instructions)
Employer identi cation number
21
Address (number, street, and apt. or suite no.)
22 Occupation, profession, or business
23
24 State
25 ZIP code
26 Country (if not U.S.)
City
27
Alien
a Describe ID
b Issued by
identi cation (ID)
c Number
Part III
Description of Transaction and Method of Payment
28
Date cash received
29 Total cash received
30
31 Total price if different from
If cash was received in
item 29
M
M
D
D
Y
Y
Y
Y
more than one payment,
0 1 0 6 2 0 1 3
$
.00
check here
.
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.
$
.00
18,000
32
Amount of cash received (in U.S. dollar equivalent) (must equal item 29) (see instructions):
$
(Amount in $100 bills or higher $
.00 )
a
U.S. currency
18,000
.00
$
)
b
(Country
Foreign currency
.00
}
$
c
Cashier’s check(s)
.00
Issuer’s name(s) and serial number(s) of the monetary instrument(s)
$
d
Money order(s)
.00
$
e
Bank draft(s)
.00
f
Traveler’s check(s)
$
.00
33
34 Speci c description of property or service shown in
Type of transaction
a
Personal property purchased
f
Debt obligations paid
33. Give serial or registration number, address, docket
b
Real property purchased
g
number, etc.
Exchange of cash
Go - Fast
c
Personal services provided
h
Escrow or trust funds
4 - door sedan serial no xx -
d
Business services provided
i
Bail received by court clerks
ABCDEFG - 1234567
e
j
Intangible property purchased
Other (specify in item 34)
Part IV
Business That Received Cash
35
Name of business that received cash
36 Employer identi cation number
1 0 1 2 3 4 5 6 7
Small Town Cars
37
Address (number, street, and apt. or suite no.)
Social security number
5000 Industrial Avenue
38
City
39 State
40 ZIP code
41 Nature of your business
P
A
Hometown
Car Dealership
10101
Under penalties of perjury, I declare that to the best of my knowledge the information I have furnished above is true, correct,
42
and complete.
Pat Brown
Sales Manager
Signature
Title
Authorized of cial
M
M
D
D
Y
Y
Y
Y
44 Type or print name of contact person
45 Contact telephone number
43 Date of
signature
0 1 0 6 2 0 1 3
Pat Brown
999-555-0555
8300
8300
IRS Form
(Rev. 7-2012)
FinCEN Form
(Rev. 7-2012)
Cat. No. 62133S
Page 6
Publication 1544 (September 2012)
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