Fincen Form 104 - Currency Transaction Report Page 2
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4FinCEN Form 104 (formerly Form 4789) (Eff. 12-03)
Page 2
Multiple Persons
Complete applicable parts below if box 1b on page 1 is checked
Part I
Person(s) Involved in Transaction(s)
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
2 Individual’s last name or entity’s name
3 First name
4 Middle initial
5 Doing business as (DBA)
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
8 Date of birth
____/____/_______
MM
DD
YYYY
12 Country code
9 City
10 State
11 ZIP code
13 Occupation, profession, or business
(if not U.S.)
14 If an individual, describe method used to verify identity:
b
Passport
a
Driver’s license/State I.D.
c
Alien registration
e Issued by:
d
Other
f Number:
Section B--Individual(s) Conducting Transaction(s) (if other than above).
15 Individual’s last name
17 Middle initial
16 First name
18 Address (number, street, and apt. or suite no.)
19 SSN
24 Date of birth
20 City
21 State
22 ZIP code
23 Country code
____/____/_______
(if not U.S.)
MM
DD
YYYY
25 If an individual, describe method used to verify identity:
b
Passport
c
Alien registration
a
Driver’s license/State I.D.
e Issued by:
f Number:
d
Other
Part I
Person(s) Involved in Transaction(s)
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
2 Individual’s last name or entity’s name
3 First name
4 Middle initial
5 Doing business as (DBA)
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
8 Date of birth
____/____/_______
MM
DD
YYYY
10 State 11 ZIP code
9 City
12 Country code
13 Occupation, profession, or business
(if not U.S.)
14 If an individual, describe method used to verify identity:
b
Passport
a
Driver’s license/State I.D.
c
Alien registration
f Number:
d
Other
e Issued by:
Section B--Individual(s) Conducting Transaction(s) (if other than above).
15 Individual’s last name
17 Middle initial
16 First name
18 Address (number, street, and apt. or suite no.)
19 SSN
24 Date of birth
20 City
21 State
22 ZIP code
23 Country code
____/____/_______
(if not U.S.)
MM
DD
YYYY
25 If an individual, describe method used to verify identity:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
e Issued by:
f Number:
d
Other
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