Currency Transaction Report - Form 4789 (Page 3 of 4) in pdf

Form 4789 (Rev. 10-95)

Page

copy of each CTR for five years from the date

previously, check Item 1a. Staple a copy of the

Paperwork Reduction Act Notice.—The

requested information has been determined to

filed.

original CTR to the amended one, complete Part

be useful in criminal, tax, and regulatory

III fully and only those other entries which are

A financial institution may apply to file the

investigations and proceedings. Financial

being amended.

CTRs magnetically. To obtain an application to

institutions are required to provide the

file magnetically, write to the IRS Detroit

Item 1b. Multiple Persons.—If this transaction

information under 31 U.S.C. 5313 and 31 CFR

Computing Center, ATTN: CTR Magnetic Media

is being conducted by more than one person or

Part 103. These provisions are commonly

Coordinator, at the address listed above.

on behalf of more than one person, check Item

referred to as the Bank Secrecy Act (BSA) which

Identification Requirements.—All individuals

1b. Enter information in Part I for one of the

is administered by the U.S. Department of the

persons and provide information on any other

(except employees of armored car services)

Treasury’s Financial Crimes Enforcement

persons on the back of the CTR.

conducting a reportable transaction(s) for

Network (FinCEN).

themselves or for another person must be

Item 1c. Multiple Transactions.—If the financial

The time needed to complete this form will

identified by means of an official document(s).

institution has knowledge that there are multiple

vary depending on individual circumstances. The

transactions, check Item 1c.

Acceptable forms of identification include a

estimated average time is 19 minutes. If you

driver’s license, military, and military/dependent

have comments concerning the accuracy of this

PART I - Person(s) Involved in

identification cards, passport, state issued

time estimate or suggestions for making this

Transaction(s)

identification card, cedular card (foreign),

form simpler, we would be happy to hear from

non-resident alien identification cards, or any

you. You can write to the Internal Revenue

Section A must be completed. If an individual

other identification document or documents,

Service, Attention: Tax Forms Committee,

conducts a transaction on his own behalf,

which contain name and preferably address and

PC:FP, Washington, DC 20224. DO NOT send

complete Section A; leave Section B BLANK. If

a photograph and are normally acceptable by

this form to this office. Instead, see When and

an individual conducts a transaction on his own

financial institutions as a means of identification

Where To File below.

behalf and on behalf of another person(s),

when cashing checks for persons other than

complete Section A for each person; leave

Suspicious Transactions

established customers.

Section B BLANK. If an individual conducts a

Acceptable identification information obtained

transaction on behalf of another person(s),

This Currency Transaction Report (CTR) should

previously and maintained in the financial

complete Section B for the individual conducting

NOT be filed for suspicious transactions

institution’s records may be used. For example,

the transaction, and complete Section A for each

involving $10,000 or less in currency OR to note

if documents verifying an individual’s identity

person on whose behalf the transaction is

that a transaction of more than $10,000 is

were examined and recorded on a signature

conducted of whom the financial institution has

suspicious. Any suspicious or unusual activity

card when an account was opened, the financial

knowledge.

should be reported by a financial institution in

institution may rely on that information. In

the manner prescribed by its appropriate federal

Section A. Person(s) on Whose Behalf

completing the CTR, the financial institution

regulator or BSA examiner. (See Item 37.) If a

Transaction(s) Is Conducted.—See instructions

must indicate on the form the method, type, and

transaction is suspicious and in excess of

above.

number of the identification. Statements such as

$10,000 in currency, then both a CTR and the

Items 2, 3, and 4. Individual/Organization

“known customer” or “signature card on file” are

appropriate referral form must be filed.

Name.—If the person on whose behalf the

not sufficient for form completion.

Should the suspicious activity require

transaction(s) is conducted is an individual, put

Penalties.—Civil and criminal penalties are

immediate attention, financial institutions should

his/her last name in Item 2, first name in Item 3

provided for failure to file a CTR or to supply

telephone 1-800-800-CTRS. An Internal Revenue

and middle initial in Item 4. If there is no middle

information or for filing a false or fraudulent CTR.

Service (IRS) employee will direct the call to the

initial, leave item 4 BLANK. If the transaction is

See 31 U.S.C. 5321, 5322 and 5324.

local office of the IRS Criminal Investigation

conducted on behalf of an organization, put its

For purposes of this CTR, the terms below

Division (CID). This toll-free number is

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

have the following meanings:

operational Monday through Friday, from

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

approximately 9:00 am to 6:00 pm Eastern

Currency.—The coin and paper money of the

financial institution has knowledge of a separate

Standard Time. If an emergency, consult

United States or any other country, which is

“doing business as” name, enter it in Item 5. For

directory assistance for the local IRS CID Office.

circulated and customarily used and accepted as

example, Johnson Enterprises DBA PJ’s Pizzeria.

money.

General Instructions

Item 6. Social Security Number (SSN) or

Person.—An individual, corporation, partnership,

Employer Identification Number (EIN).—Enter

trust or estate, joint stock company, association,

the SSN or EIN of the person identified in Item 2.

Who Must File.—Each financial institution (other

syndicate, joint venture or other unincorporated

If none, write NONE.

than a casino, which instead must file Form

organization or group.

8362 and the U.S. Postal Service for which there

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

are separate rules), must file Form 4789 (CTR)

Organization.—Person other than an individual.

permanent street address including zip code of

for each deposit, withdrawal, exchange of

the person identified in Item 2. Use the Post

Transaction In Currency.—The physical

currency, or other payment or transfer, by,

Office’s two letter state abbreviation code. A

transfer of currency from one person to another.

through, or to the financial institution which

P.O. Box should not be used by itself and may

This does not include a transfer of funds by

involves a transaction in currency of more than

only be used if there is no street address. If a

means of bank check, bank draft, wire transfer

$10,000. Multiple transactions must be treated

P.O. Box is used, the name of the apartment or

or other written order that does not involve the

as a single transaction if the financial institution

suite number, road or route number where the

physical transfer of currency.

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

person resides must also be provided. If the

Negotiable Instruments.—All checks and drafts

of the same person, and (2) they result in either

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

(including business, personal, bank, cashier’s

currency received (Cash In) or currency

address, city, province, or state, postal code (if

and third-party), money orders, and promissory

disbursed (Cash Out) by the financial institution

known), and the name of the country.

notes. For purposes of this CTR, all traveler’s

totaling more than $10,000 during any one

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

checks shall also be considered negotiable

business day. For a bank, a business day is the

Six numerals must be inserted for each date.

instruments. All such instruments shall be

day on which transactions are routinely posted

The first two will reflect the month of birth, the

considered negotiable instruments whether or

to customers’ accounts, as normally

second two the calendar day of birth, and the

not they are in bearer form.

communicated to depository customers. For all

last two numerals the year of birth. Zero (0)

other financial institutions, a business day is a

Specific Instructions

should precede any single digit number. For

calendar day.

example, if an individual’s birth date is April 3,

Because of the limited space on the front and

Generally, financial institutions are defined as

1948, Item 8 should read 04 03 48.

back of the CTR, it may be necessary to submit

banks, other types of depository institutions,

Item 13. Occupation, Profession, or

additional information on attached sheets.

brokers or dealers in securities, money

Business.—Identify fully the occupation,

Submit this additional information on plain paper

transmitters, currency exchangers, check

profession or business of the person on

attached to the CTR. Be sure to put the

cashers, issuers and sellers of money orders and

whose behalf the transaction(s) was

individual’s or organization’s name and

traveler’s checks. Should you have questions,

conducted. For example, secretary, shoe

identifying number (items 2, 3, 4, and 6 of the

see the definitions in 31 CFR Part 103.

salesman, carpenter, attorney, housewife,

CTR) on any additional sheets so that if it

When and Where To File.—File this CTR by the

restaurant, liquor store, etc. Do not use

becomes separated, it may be associated with

15th calendar day after the day of the

non-specific terms such as merchant,

the CTR.

transaction with the IRS Detroit Computing

self-employed, businessman, etc.

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

Center, ATTN: CTR, P.O. Box 33604, Detroit, MI

being filed because it amends a report filed

48232-5604 or with your local IRS office. Keep a

Currency Transaction Report - Form 4789 Page 3

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