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OMB NO. 1506-0014

DEPARTMENT OF THE TREASURY

105

FINANCIAL CRIMES ENFORCEMENT NETWORK

To be filed with the Bureau of

FinCEN Form

Customs and Border Protection

(Formerly Customs Form 4790)

REPORT OF INTERNATIONAL

For Paperwork Reduction Act

(Rev. July 2003)

TRANSPORTATION OF CURRENCY

Notice and Privacy Act Notice,

Department of the Treasury

see back of form.

FinCEN

OR MONETARY INSTRUMENTS

Please type or print.

31 U.S.C. 5316; 31 CFR 103.23 and 103.27

FOR A PERSON DEPARTING OR ENTERING THE UNITED STATES, OR A PERSON SHIPPING, MAILING, OR RECEIVING CURRENCY OR

P A R T I

MONETARY INSTRUMENTS. (IF ACTING FOR ANYONE ELSE, ALSO COMPLETE PART II BELOW.)

2. IDENTIFICATION NO. (See instructions)

3. DATE OF BIRTH (Mo./Day/Yr.)

1. NAME (Last or family, first, and middle)

5. YOUR COUNTRY OR COUNTRIES OF

4. PERMANENT ADDRESS IN UNITED STATES OR ABROAD

CITIZENSHIP

6. ADDRESS WHILE IN THE UNITED STATES

7. PASSPORT NO. & COUNTRY

8. U.S. VISA DATE (Mo./Day/Yr.)

9. PLACE UNITED STATES VISA WAS ISSUED

10. IMMIGRATION ALIEN NO.

11. IF CURRENCY OR MONETARY INSTRUMENT IS ACCOMPANIED BY A PERSON, COMPLETE 11a OR 11b

A. EXPORTED FROM THE UNITED STATES

B. IMPORTED INTO THE UNITED STATES

Departed From: (U.S. Port/City in U.S.)

Arrived At: (Foreign City/Country)

Departed From: (Foreign City/Country)

Arrived At: (City in U.S.)

12. IF CURRENCY OR MONETARY INSTRUMENT WAS MAILED OR OTHERWISE SHIPPED, COMPLETE 12a THROUGH 12f

12b. DATE RECEIVED (Mo./Day/Yr.) 12c. METHOD OF SHIPMENT (e.g. u.s. Mail, Public Carrier, etc.)

12d. NAME OF CARRIER

12a. DATE SHIPPED (Mo./Day/Yr.)

12e. SHIPPED TO (Name and Address)

12f. RECEIVED FROM (Name and Address)

P A R T II

INFORMATION ABOUT PERSON(S) OR BUSINESS ON WHOSE BEHALF IMPORTATION OR EXPORTATION WAS CONDUCTED

13. NAME (Last or family, first, and middle or Business Name)

14. PERMANENT ADDRESS IN UNITED STATES OR ABROAD

15a. IS THE BUSINESS A BANK?

15. TYPE OF BUSINESS ACTIVITY, OCCUPATION, OR PROFESSION

Yes

P A R T III

CURRENCY AND MONETARY INSTRUMENT INFORMATION (SEE INSTRUCTIONS ON REVERSE)(To be completed by everyone)

17. IF OTHER THAN U.S. CURRENCY

16. TYPE AND AMOUNT OF CURRENCY/MONETARY INSTRUMENTS

IS INVOLVED, PLEASE COMPLETE

BLOCKS A AND B.

Currency and Coins

A. Currency Name

Other Monetary Instruments

(Specify type, issuing entity and date, and serial or other identifying number.)

B. Country

(TOTAL)

P A R T IV

SIGNATURE OF PERSON COMPLETING THIS REPORT

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief it is true, correct and complete.

20. DATE OF REPORT (Mo./Day/Yr.)

19. SIGNATURE

18. NAME AND TITLE (Print)

VOLUNTARY

COUNT VERIFIED

REPORT

CUSTOMS AND BORDER PROTECTION USE ONLY

Yes

DATE

AIRLINE/FLIGHT/VESSEL

LICENSE PLATE

INSPECTOR (Name and Badge Number)

STATE/COUNTRY

NUMBER

FinCEN FORM 105

(Formerly Customs Form 4790)

Fincen Form 105 - Report Of International Transportation Of Currency Or Monetary Instruments

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