Fillable Fincen Form 104 - Currency Transaction Report (Page 3 of 4) in pdf

Page 3

FinCEN Form 104 (Eff. 12-03)

Suspicious Transactions

Item 1c. Multiple Transactions. If the financial institution

document(s). Acceptable forms of identification include

has knowledge that there are multiple transactions, check

driver’s license, military and military/dependent

Item 1c.

This Currency Transaction Report (CTR) should NOT be

identification cards, passport, state issued identification

card, cedular card (foreign), non-resident alien

filed for suspicious transactions involving $10,000 or less

PART I - Person(s) Involved in Transaction(s)

in currency OR to note that a transaction of more than

identification cards, or any other identification document

or documents, which contain name and preferably

$10,000 is suspicious. Any suspicious or unusual activity

Section A must be completed. If an individual conducts

should be reported by a financial institution in the manner

address and a photograph and are normally acceptable

a transaction on his own behalf, complete Section A and

by financial institutions as a means of identification when

prescribed by its appropriate federal regulator or BSA

leave Section “B” BLANK. If an individual conducts a

examiner. (See the instructions for Item 37). If a

cashing checks for persons other than established

transaction on his own behalf and on behalf of another

customers.

transaction is suspicious and in excess of $10,000 in

person(s), complete Section “A” for each person and

currency, then both a CTR and the appropriate Suspicious

leave Section “B” BLANK. If an individual conducts a

Acceptable identification information obtained previously

Activity Report form must be filed.

transaction on behalf of another person(s), complete

and maintained in the financial institution’s records may

Section “B” for the individual conducting the transaction,

be used. For example, if documents verifying an

In situations involving suspicious transactions

and complete Section “A” for each person on whose

individual’s identity were examined and recorded on a

requiring immediate attention, such as when a

behalf the transaction is conducted of whom the financial

signature card when an account was opened, the financial

reportable transaction is ongoing, the fianacial

institution has knowledge.

institution may rely on that information. In completing the

institution shall immediately notify, by telephone,

CTR, the financial institution must indicate on the form

appropriate law enforcement and regulatory

Section A. Person(s) on Whose Behalf Transaction(s)

the method, type, and number of the identification.

authorities in addition to filing a timely suspicious

Is Conducted. See instructions above.

Statements such as “known customer” or “signature card

activity report.

on file” are not sufficient for form completion.

Items 2, 3, and 4. Individual/Organization Name. If

General Instructions

Penalties. Civil and criminal penalties are provided for

the person on whose behalf the transaction(s) is conducted

failure to file a CTR or to supply information or for filing a

is an individual, put his/her last name in Item 2, first

Who Must File. Each financial institution (other than a

false or fraudulent CTR. See 31 U.S.C. 5321, 5322 and

name in Item 3, and middle initial in Item 4. If there is no

casino, which instead must file FinCEN Form 103, and

5324.

middle initial, leave item 4 BLANK. If the transaction is

the U.S. Postal Service for which there are separate rules)

conducted on behalf of an entity, enter the name in Item

must file FinCEN Form 104 (CTR) for each deposit,

For purposes of this CTR, the terms below have the

2 and leave Items 3 and 4 BLANK.

withdrawal, exchange of currency, or other payment or

following meanings:

transfer, by, through, or to the financial institution which

Item 5. Doing Business As (DBA). If the financial

involves a transaction in currency of more than $10,000.

Currency. The coin and paper money of the United

institution has knowledge of a separate “doing business

Multiple transactions must be treated as a single

States or any other country, which is circulated and

as” name, enter it in Item 5. For example, if Smith

customarily used and accepted as money.

transaction if the financial institution has knowledge that

Enterprise is doing business as MJ’s Pizza, enter “MJ’s

(1) they are by or on behalf of the same person, and (2)

Pizza” in item 5.

Person. An individual, corporation, partnership, trust or

they result in either currency received (Cash In) or currency

estate, joint stock company, association, syndicate, joint

disbursed (Cash Out) by the financial institution totaling

Item 6. SSN or EIN. Enter the Social Security Number

venture or other unincorporated organization or group.

more than $10,000 during any one business day. For a

(SSN) or Individual Taxpayer Identification Number (ITIN)

bank, a business day is the day on which transactions are

or Employer Identification Number (EIN) of the person or

Organization. Entity other than an individual.

routinely posted to customers’ accounts, as normally

entity identified in Item 2. If none, write NONE.

communicated to depository customers. For all other

Transaction in Currency. The physical transfer of

financial institutions, a business day is a calendar day.

Items 7, 9, 10, 11, and 12. Address. Enter the permanent

currency from one person to another. This does not

address including ZIP Code of the person identified in

include a transfer of funds by means of bank check, bank

Generally, financial institutions are defined as banks,

Item 2. Use the U.S. Postal Service’s two letter state

draft, wire transfer or other written order that does not

other types of depository institutions, brokers or dealers

abbreviation code. A P . O. Box should not be used by

involve the physical transfer of currency.

in securities, money transmitters, currency exchangers,

itself, and may only be used if there is no street address.

check cashers, and issuers and sellers of money orders

If a P . O. Box is used, the name of the apartment or suite

Negotiable Instruments. All checks and drafts (including

and traveler’s checks. Should you have questions, see

number, road or route number where the person resides

business, personal, bank, cashier’s and third-party),

the definitions in 31 CFR Part 103.

must also be provided. If the address is outside the

money orders, and promissory notes. For purposes of

this CTR, all traveler’s checks shall also be considered

U.S., provide the street address, city, province or state,

When and Where To File. This form should be e-

negotiable instruments whether or not they are in bearer

postal code (if known), and the two letter country code.

filed through the Bank Secrecy Act E-filing System.

form.

For country code list go to

Go to http: //bsaefiling.fincen.treas.gov/index.jsp to

reg_bsaforms.html or telephone 800-949-2732 and select

Foreign exchange rate.

If foreign currency is a part of

option number 5. If U.S., leave item 12 blank.

Financial Crimes Enforcement Network’s Web site at

a currency transaction that requires the completion of a

, or may be ordered by calling the IRS

CTR, use the exchange rate in effect for the business

Item 8. Date of Birth. Enter the date of birth. Eight

Forms Distribution Center at (800) 829-3676. File this

day of the transaction to compute the amount, in US

numerals must be inserted for each date. The first two

CTR by the 15th calendar day after the day of the

dollars, to enter in item 26/27.

The source of the exchange

will reflect the month, the second two the day, and the

transaction with the:

rate that is used will be determined by the reporting

last four the year. A zero (0) should precede any single

institution.

digit number. For example, if an individual’s birth date is

Enterprise Computing Center - Detroit

April 3 1948, Item 8 should read 04 03 1948.

ATTN: CTR

Specific Instructions

P .O. Box 33604

Because of the limited space on the front and back of the

Item 13. Occupation, profession, or business . If

Detroit, MI 48232-5604

CTR, it may be necessary to submit additional information

known, identify the occupation, profession or business

on attached sheets. Submit this additional information on

that best describes the individual or entity in Part I (e.g.,

Keep a copy of each CTR for five years from the date

plain paper attached to the CTR. Be sure to put the

attorney, car dealer, carpenter, doctor, farmer, plumber,

filed.

individual’s or entity’s name and identifying number (items

truck driver, etc.). Do not use nondescript terms such as

2, 3, 4, and 6 of the CTR) on any additional sheets so that

businessman, merchant, store owner (unless store’s name

A financial institution may apply to file the CTRs

if it becomes separated, it may be associated with the

is provided), or self employed. If unemployed, or retired

magnetically. To obtain an application to file magnetically,

CTR.

are used enter the regular or former occupation if known.

write to the:

Item 1a. Amends Prior Report. If this CTR is being

IRS Detroit Computing Center

Item 14. If an Individual, Describe Method Used To

filed because it amends a report filed previously, check

Verify Identity.

If an individual conducts the

ATTN: CTR Magnetic Media Coordinator

Item 1a. Staple a copy of the original CTR to the amended

P .O. Box 33604

transaction(s) on his/her own behalf, his/her identity must

one, complete Part III fully and only those other entries

Detroit, MI 48232-5604

be verified by examination of an acceptable document

which are being amended.

(see General Instructions). For example, check box a if

Identification Requirements. All individuals (except a

a driver’s license is used to verify an individual’s identity,

Item 1b. Multiple Persons. If this transaction is being

employees of armored car services) conducting a

and enter the state that issued the license and the number

conducted by more than one person or on behalf of more

reportable transaction(s) for themselves or for another

in items e and f. If the transaction is conducted by an

than one person, check Item 1b. Enter information in Part

person, must be identified by means of an official

individual on behalf of another individual not present, or

I for one of the persons and provide information on any

on behalf of an entity, check box “14d” “Other” and

other persons on the back of the CTR.

enter “NA” on the line provided.

Fincen Form 104 - Currency Transaction Report Page 3

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