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Fincen Form 105 - Report Of International Transportation Of Currency Or Monetary Instruments - 2011

105

REPORT OF INTERNATIONAL

TRANSPORTATION OF CURRENCY

OR MONETARY INSTRUMENTS

Please type or print.

P A R T I

(See instructions)

(Mo./Day/Yr.)

(Last or family, first, and middle)

(Mo./Day/Yr.)

COMPLETE 11a OR 11b, not both

COMPLETE “A” OR “B” NOT BOTH

(U.S. Port/City in U.S.)

(Foreign City/Country)

(City in U.S.)

(e.g. u.s. Mail, Public Carrier, etc.)

(Mo./Day/Yr.)

(Name and Address)

P A R T II

INFORMATION ABOUT PERSON(S) OR BUSINESS ON WHOSE BEHALF IMPORTATION OR EXPORTATION WAS CONDUCTED

(Last or family, first, and middle or Business Name)

P A R T III

CURRENCY AND MONETARY INSTRUMENT INFORMATION (SEE INSTRUCTIONS ON REVERSE)(To be completed by everyone)

(Specify type, issuing entity and date, and serial or other identifying number.)

(TOTAL)

P A R T IV

SIGNATURE OF PERSON COMPLETING THIS REPORT

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief it is true, correct and complete.

(Mo./Day/Yr.)

CUSTOMS AND BORDER PROTECTION USE ONLY

(Name and Badge Number)

Fincen Form 105 - Report Of International Transportation Of Currency Or Monetary Instruments - 2011