Currency Transaction Report - Form 4789
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44789
Currency Transaction Report
Form
Use this 1995 revision effective October 1, 1995.
(Rev. October 1995)
OMB No. 1545-0183
For Paperwork Reduction Act Notice, see page 3.
Please type or print.
Department of the Treasury
(Complete all parts that apply—See instructions)
Internal Revenue Service
1
Check all box(es) that apply:
a
Amends prior report
b
Multiple persons
c
Multiple transactions
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 Organization’s name
3
First name
4
M.I.
5
Doing business as (DBA)
6
SSN or EIN
7
Address (number, street, and apt. or suite no.)
8
Date
M
M
D
D
Y
Y
of
birth
9
City
10
State
11
ZIP code
12
Country (if not U.S.)
13
Occupation, profession, or business
14
If an individual, describe method used to verify identity:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
d
Other
e
Issued by:
f
Number:
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):
Night Deposit or Automated Teller Machine (ATM)
Armored Car Service
b
c
a
Mail Deposit or Shipment
d
Multiple Transactions
e
Conducted On Own Behalf
15
Individual’s last name
16
First name
17
M.I.
18
Address (number, street, and apt. or suite no.)
19
SSN
20
City
21
State
22
ZIP code
23
Country (if not U.S.)
24
Date
M
M
D
D
Y
Y
of
birth
25
If an individual, describe method used to verify identity:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
d
Other
e
Issued by:
f
Number:
Amount and Type of Transaction(s). Check all boxes that apply.
Part II
28
Date
M
M
D
D
Y
Y
of
.00
.00
Transaction
26
Cash In $
27
Cash Out $
29
Foreign Currency
30
Wire Transfer(s)
31
Negotiable Instrument(s) Purchased
(Country)
32
Negotiable Instrument(s) Cashed
33
Currency Exchange(s)
34
Deposit(s)/Withdrawal(s)
35
Account Number(s) Affected (if any):
36
Other (specify)
Part III
Financial Institution Where Transaction(s) Takes Place
37
Name of financial institution
Enter Federal Regulator or BSA Examiner code
[
]
number from the instructions here.
38
Address (number, street, and apt. or suite no.)
39
SSN or EIN
40
City
41
State
42 ZIP code
43 MICR No.
44
Title of approving official
45
Signature of approving official
46
Date
M
M
D
D
Y
Y
of
Sign
signature
Here
47
Type or print preparer’s name
48
Type or print name of person to contact
49
Telephone number
(
)
4789
Cat. No. 42004W
Form
(Rev. 10-95)
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