Form 104 - Currency Transaction Report Form - 2003
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4104
Currency Transaction Report
FINCEN Form
(Formerly Form 4789)
Previous editions will not be accepted after August 31, 2004.
(Eff. December 2003)
Please type or print.
Department of the Treasury
(Complete all parts that apply--See Instructions)
OMB No. 1506-0004
FinCEN
1
Check all box(es) that apply:
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.)
10 State
11 ZIP code
12 Country code
9
City
13 Occupation, profession, or business
(if not U.S.)
14
If an individual, describe method used to verify identity:
Section B--Individual(s) Conducting Transaction(s) (if other than above).
If Section B is left blank or incomplete, check the box(es) below to indicate the reason(s)
15
Individual’s last name
16 First name
17 Middle initial
18
Address (number, street, and apt. or suite no.)
19 SSN
20
City
21 State
22 ZIP code
23 Country code
(If not U.S.)
25
If an individual, describe method used to verify identity:
26
Total cash in $
.00
Enter Regulator or BSA
37 Name of financial institution
Examiner code number
(see instructions)
38
Address (number, street, and apt. or suite no.)
41 State
42 ZIP code
43 Routing (MICR) number
40
City
45 Signature of approving official
44 Title of approving official
47 Type or print preparer’s name
48 Type or print name of person to contact
49 Telephone number
FinCEN Form 104 (Formerly Form 4789) (Rev. 8-03)
Cat. No. 37683N
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