Form 104 - Currency Transaction Report Form - 2003 Page 2
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4FinCEN Form 104 (formerly Form 4789) (Rev. 8-03)
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
10 State
11 ZIP code
9
City
13 Occupation, profession, or business
12 Country code
(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:
a
Driver’s license/State I.D. b
Passport
c
Alien registration
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
13 Occupation, profession, or business
12 Country code
(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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