Fillable Form 104 - Currency Transaction Report Form

Page 3

FinCEN Form 104 (Formerly Form 4789 (Rev. 8-03)

or documents, which contain name and preferably

Suspicious Transactions

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

address and a photograph and are normally acceptable

by financial institutions as a means of identification when

Section A must be completed. If an individual conducts

This Currency Transaction Report (CTR) should NOT be

cashing checks for persons other than established

a transaction on his own behalf, complete Section A and

filed for suspicious transactions involving $10,000 or less

customers.

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

in currency OR to note that a transaction of more than

transaction on his own behalf and on behalf of another

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

Acceptable identification information obtained

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

should be reported by a financial institution in the

previously and maintained in the financial institution’s

Section “B” BLANK. If an individual conducts a

manner prescribed by its appropriate federal regulator

records may be used. For example, if documents

transaction on behalf of another person(s), complete

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

verifying an individual’s identity were examined and

Section “B” for the individual conducting the transaction,

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

recorded on a signature card when an account was

and complete Section “A” for each person on whose

currency, then both a CTR and the appropriate

opened, the financial institution may rely on that

behalf the transaction is conducted of whom the financial

Suspicious Activity Report form must be filed.

information. In completing the CTR, the financial

institution has knowledge.

institution must indicate on the form the method, type,

Should the suspicious activity require immediate

and number of the identification. Statements such as

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

attention, financial institutions should telephone

“known customer” or “signature card on file” are not

Is Conducted. See instructions above.

1-800-800-CTRS. An Internal Revenue Service (IRS)

sufficient for form completion.

employee will direct the call to the local office of the

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

IRS Criminal Investigation Division (CI). This toll-free

Penalties. Civil and criminal penalties are provided for

the person on whose behalf the transaction(s) is

number is operational Monday through Friday, from

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

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

approximately 9:00 am to 6:00 pm Eastern Standard

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

2, first name in Item 3, and middle initial in Item 4. If

Time. If an emergency, consult directory assistance for

and 5324.

there is no middle initial, leave item 4 BLANK. If the

the local IRS CID Office.

transaction is conducted on behalf of an entity, put its

For purposes of this CTR, the terms below have the

name in Item 2 and leave Items 3 and 4 BLANK.

General Instructions

following meanings:

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

Who Must File. Each financial institution (other than a

Currency. The coin and paper money of the United

institution has knowledge of a separate “doing business

casino, which instead must file FinCEN Form 103, and

States or any other country, which is circulated and

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

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

customarily used and accepted as money.

Enterprise DBA MJ’s Pizza.

must file FinCEN Form 104 (formerly 4789) (CTR) for

each deposit, withdrawal, exchange of currency, or other

Person. An individual, corporation, partnership, trust

Item 6. SSN/ITIN or EIN. Enter the Social Security

payment or transfer, by, through, or to the financial

or estate, joint stock company, association, syndicate,

Number (SSN) or Individual Taxpayer Identification

joint venture or other unincorporated organization or

institution which involves a transaction in currency of

Number (ITIN) or Employer Identification Number (EIN)

group.

more than $10,000. Multiple transactions must be

of the person or entity identified in Item 2. If none,

treated as a single transaction if the financial institution

write NONE.

Organization. Entity other than an individual.

has knowledge that (1) they are by or on behalf of the

same person, and (2) they result in either currency

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

Transaction in Currency. The physical transfer of

received (Cash In) or currency disbursed (Cash Out) by

permanent address including ZIP Code of the person

currency from one person to another. This does not

the financial institution totaling more than $10,000

identified in Item 2. Use the U.S. Postal Service’s two

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

during any one business day. For a bank, a business day

letter state abbreviation code. A P . O. Box should not

draft, wire transfer or other written order that does not

is the day on which transactions are routinely posted to

be used by itself, and may only be used if there is no

involve the physical transfer of currency.

customers’ accounts, as normally communicated to

street address. If a P . O. Box is used, the name of the

depository customers. For all other financial institutions,

apartment or suite number, road or route number where

Negotiable Instruments. All checks and drafts (including

a business day is a calendar day.

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

the person resides must also be provided. If the address

money orders, and promissory notes. For purposes of

is outside the U.S., provide the street address, city,

Generally, financial institutions are defined as banks,

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

province or state, postal code (if known), and the two

other types of depository institutions, brokers or dealers

negotiable instruments whether or not they are in bearer

letter country code. For country code list go to

in securities, money transmitters, currency exchangers,

form.

or telephone

check cashers, and issuers and sellers of money orders

1-800-949-2732 and select option number 5. If U.S.,

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

Foreign exchange rates. If completing items 26a/27a,

leave item 12 blank.

the definitions in 31 CFR Part 103.

use the exchange rate in effect for the business day of

the transaction. The source of the exchange rate that is

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

When and Where To File. File this CTR by the 15th

used will be determined by the reporting institution.

numerals must be inserted for each date. The first two

calendar day after the day of the transaction with the:

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

Specific Instructions

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

IRS Detroit Computing Center

Because of the limited space on the front and back of

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

ATTN: CTR

the CTR, it may be necessary to submit additional

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

P .O. Box 33604

information on attached sheets. Submit this additional

Detroit, MI 48232-5604

information on plain paper attached to the CTR. Be sure

Item 13. Occupation, Profession, or Business. Identify

to put the individual’s or entity’s name and identifying

the occupation, profession, or business of the person on

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

number (items 2, 3, 4, and 6 of the CTR) on any

whose behalf the transaction was conducted. For

filed.

additional sheets so that if it becomes separated, it may

example: secretary, shoe salesman, carpenter, attorney,

be associated with the CTR.

housewife, restaurant, liquor store,etc. Do not use non-

A financial institution may apply to file the CTRs

specific terms such as merchant, self-employed,

magnetically. To obtain an application to file magnetically,

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

businessman, etc.

write to the:

filed because it amends a report filed previously, check

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

Item 14. If an Individual, Describe Method Used To

IRS Detroit Computing Center

amended one, complete Part III fully and only those other

Verify Identity. If an individual conducts the

ATTN: CTR Magnetic Media Coordinator

entries which are being amended.

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

P .O. Box 33604

be verified by examination of an acceptable document

Detroit, MI 48232-5604

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

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

conducted by more than one person or on behalf of

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

Identification Requirements. All individuals (except

more than one person, check Item 1b. Enter information

and enter the state that issued the license and the number

employees of armored car services) conducting a

in Part I for one of the persons and provide information

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

reportable transaction(s) for themselves or for another

on any other persons on the back of the CTR.

individual on behalf of another individual not present

person, must be identified by means of an official

or on behalf of an entity, enter N/A in Item 14.

document(s). Acceptable forms of identification include

Item 1c. Multiple Transactions. If the financial

a driver’s license, military and military/dependent

institution has knowledge that there are multiple

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

identification cards, passport, state issued identification

transactions, check Item 1c.

(if other than above). Financial institutions should enter

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

as much information as is available.

identification cards, or any other identification document

Form 104 - Currency Transaction Report Form - 2003 Page 3

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