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

Page 4

FinCEN Form 104 (Eff. 12-03)

Section B. Individual(s) Conducting Transaction(s)

If there is a currency exchange, it should be aggregated

Item 36. Other (specify). If a transaction is not identified

(if other than above). Financial institutions should enter

separately with each of the Cash In and Cash Out totals.

in Items 30-34, check Item 36 and provide an additional

as much information as is available. However, there may

description. For example, a person presents a check to

be instances in which Items 15-25 may be left BLANK or

purchase “foreign currency.” If

multiple (more than one)

Example 1: A person deposits $11,000 in currency to his

foreign currencies are involved in the transaction, enter

incomplete. If Items 15-25 are left BLANK or incomplete,

savings account and withdraws $3,000 in currency from

the amount of the largest foreign currency transaction in

check one or more of the boxes provided to indicate the

his checking account. The CTR should be completed as

item 26a or 27a and that currency’s country-code of

reasons.

follows:

origin in item 29. Then check box 36 and enter the

Cash In $11,000 and no entry for Cash Out. This is

additional foreign currencies amount(s) and country-

Example: If there are multiple transactions that, if only

because the $3,000 transaction does not meet the reporting

code(s) of origin in the space provided.

when aggregated, the financial institution has knowledge

threshold.

the transactions exceed the reporting threshold, and

PART III - Financial Institution Where Transaction(s)

therefore, did not identify the transactor(s), check box d

Example 2: A person deposits $11,000 in currency to his

Take Place

for Multiple Transactions.

savings account and withdraws $12,000 in currency from

his checking account. The CTR should be completed as

Item 37. Name of Financial Institution and Identity of

Items 15, 16, and 17. Individual’s Name. Complete

follows:

Regulator or BSA Examiner. Enter the financial

these items if an individual conducts a transaction(s) on

Cash In $11,000, Cash Out $12,000. This is because

institution’s full legal name and identify the regulator or

behalf of another person. For example, if John Doe, an

there are two reportable transactions. However, one

BSA examiner, using the following codes:

employee of XY Grocery Store, makes a deposit to the

CTR may be filed to reflect both.

store’s account, XY Grocery Store should be identified in

Regulator or BSA Examiner

CODE

Section A and John Doe should be identified in section B.

Example 3: A person deposits $6,000 in currency to his

Comptroller of the Currency (OCC).........................1

savings account and withdraws $4,000 in currency from

Federal Deposit Insurance Corporation (FDIC)..........2

Items 18, 20, 21, 22, and 23. Address. Enter the

his checking account. Further, he presents $5,000 in

Federal Reserve System (FRS).................................3

permanent street address including ZIP Code of the

currency to be exchanged for the equivalent in Euro’s.

Office of Thrift Supervision (OTS)............................4

individual. (See the instructions for Items 7 and 9 through

The CTR should be completed as follows:

National Credit Union Administration (NCUA)...........5

12.) Enter country code if not U.S. (Reference item 12).

Cash In $11,000 and no entry for Cash Out. This is

Securities and Exchange Commission (SEC)..............6

because in determining whether the transactions are

Internal Revenue Service (IRS)................................7

Item 19. SSN/ITIN. If the individual has a Social Security

reportable, the currency exchange is aggregated with

U.S. Postal Service (USPS)......................................8

Number, or Individual Taxpayer Indentifcation Number,

each of the Cash In and Cash Out amounts. The result is

Commodity Futures Trading Commission (CFTC)........9

enter it in Item 19. If the individual does not have an

a reportable $11,000 Cash In transaction. The total Cash

State Regulator....................................................10

SSN/ITIN, enter NONE.

Out amount is $9,000, which does not meet the reporting

threshold. Therefore, it is not entered on the CTR.

Items 38, 40, 41, and 42. Address. Enter the street

Item 24. Date of Birth. Enter the individual’s date of

address, city, state, and ZIP Code of the financial

birth. (See the instructions for Item 8.)

Example 4: A person deposits $6,000 in currency to his

institution where the transaction occurred. If there are

savings account and withdraws $7,000 in currency from

multiple transactions, provide information of the office or

Item 25. If an Individual, Describe Method Used To

his checking account. Further, he presents $5,000 in

branch where any one of the transactions has occurred.

Verify Identity. Enter the method used to identify the

currency to be exchanged for the equivalent in Euro’s.

individual’s identity. (See General Instructions and the

The CTR should be completed as follows:

Item 39. EIN or SSN. Enter the financial institution’s EIN.

instructions for Item 14.)

Cash In $11,000, Cash Out $12,000. This is because in

If the financial institution does not have an EIN, enter the

determining whether the transactions are reportable, the

SSN of the financial institution’s principal owner.

PART II - Amount and Type of Transaction(s)

currency exchange is aggregated with each of the Cash

Complete Part II to identify the type of transaction(s)

In and Cash Out amounts. In this example, each of the

Item 43. Routing (MICR) Number. If a depository

and the amount(s) involved.

Cash In and Cash Out totals exceed $10,000 and must

institution, enter the routing (Magnetic Ink Character

be reflected on the CTR.

Recognition (MICR)) number.

Items 26 and 27. Total Cash In/Total Cash Out. In the

spaces provided, enter the total amount of currency

Items 30-33. Check the appropriate item(s) to identify

SIGNATURE

received (Total Cash In) or total currency disbursed (Total

the following type of transaction(s):

Cash Out) by the financial institution. If foreign currency

Items 44 and 45. Title and signature of Approving

30. Wire Transfer(s)

Official. The official who reviews and approves the CTR

is exchanged, use the U.S. dollar equivalent on the day

31. Negotiable Instrument(s) Purchased

must indicate his/her title and sign the CTR.

of the transaction (See “Foreign exchange rates”), and

32. Negotiable Instrument(s) Cashed

complete item 26a or 27a, whichever is appropriate.

33. Currency Exchange(s)

Item 46. Date of Signature. The approving official must

enter the date the CTR is signed. (See the instructions for

If less than a full dollar amount is involved, increase that

Item 34. Deposits/Withdrawals. Check this item to

Item 8.)

figure to the next highest dollar. For example, if the

identify deposits to or withdrawals from accounts, e.g.

currency totals $20,000.05, show the total as $20,001.00.

demand deposit accounts, savings accounts, time

Item 47. Preparer’s Name. Type or print the full name

deposits, mutual fund accounts, or any other account

of the individual preparing the CTR. The preparer and

Items 26a and 27a. Foreign cash in/Foreign cash out.

held at the financial institution. Enter the account

the approving official may not necessarily be the same

If foreign currency is exchanged, enter the amount of

number(s) in Item 35.

individual.

foreign currency (Do not convert to U.S. dollars) in items

26a and 27a. Report country of origin in item 29.

Item 35. Account Numbers Affected (if any). Enter

Items 48 and 49. Contact Person/Telephone Number.

the account numbers of any accounts affected by the

Type or print the name and telephone number of an

Item 28. Date of Transaction. Insert eight numerals for

transactions that are maintained at the financial institution

individual to contact concerning questions about the CTR.

each date. (See instructions for Item 8.)

conducting the transaction(s).

Paperwork Reduction Act Notice. The requested

Item 29. Foreign Country. If items 26a and/or 27a are

Example 1: If a person cashes a check drawn on an

information is useful in criminal, tax, and regulatory

completed indicating that foreign currency is involved,

account held at the financial institution, the CTR should

investigations and proceedings. Financial institutions are

check Item 29 and identify the country. If multiple

be completed as follows:

required to provide the information under 31 U.S.C. 5313

foreign currencies are involved, check box 36 and identify

Indicate negotiable instrument(s) cashed and provide

and 31 CFR Part 103, commonly referred to as the Bank

the additional country(s) and/or currency(s) involved.

the account number of the check.

Secrecy Act (BSA). The BSA is administered by the U.S.

Department of the Treasury ’s Financial Crimes

Determining Whether Transactions Meet the

If the transaction does not affect an account, make no

Enforcement Network (FinCEN). You are not required to

entry.

Reporting Threshold.

provide the requested information unless a form displays

a valid OMB control number. The time needed to

Example 2: A person cashes a check drawn on another

Only cash transactions that, if alone or when aggregated,

complete this form will vary depending on individual

financial institution. In this instance, negotiable

exceed $10,000 should be reported on the CTR.

circumstances. The estimated average time is 19 minutes.

instrument(s) cashed would be indicated, but no account

Transactions shall not be offset against one another.

If you have comments concerning the accuracy of this

at the financial institution has been affected. Therefore,

time estimate or suggestions for making this form simpler,

Item 35 should be left BLANK.

If there are both Cash In and Cash Out transactions that

you may write to the Financial Crimes Enforcement

are reportable, the amounts should be considered

Network, P. O. Box 39, Vienna, VA 22183. Do not send

separately and not aggregated. However, they may be

this form to this office. Instead, see When and Where

reported on a single CTR.

to File in the instructions.

Fincen Form 104 - Currency Transaction Report Page 4

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