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

Form 4789 (Rev. 10-95)

Page

Item 14. If an Individual, Describe Method

If there are both Cash In and Cash Out

at the financial institution conducting the

Used To Verify.—If an individual conducts the

transactions that are reportable, the amounts

transaction(s). If necessary, use additional sheets

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

should be considered separately and not

of paper to indicate all of the affected accounts.

identity must be verified by examination of an

aggregated. However, they may be reported on

Example 1: If a person cashes a check drawn

acceptable document (see General

a single CTR.

on an account held at the financial institution,

Instructions). For example, check box a if a

If there is a currency exchange, it should be

the CTR should be completed as follows:

driver’s license is used to verify an individual’s

aggregated separately with each of the Cash In

Indicate Negotable Instrument(s) Cashed and

identity, and enter the state that issued the

and Cash Out totals.

provide the account number of the check.

license and the number in items e and f. If the

Example 1: A person deposits $11,000 in

If the transaction does not affect an account,

transaction is conducted by an individual on

currency to his savings account and withdraws

make no entry.

behalf of another individual not present or an

$3,000 in currency from his checking account.

Example 2: A person cashes a check drawn on

organization, enter N/A in item 14.

The CTR should be completed as follows:

another financial institution. In this instance,

Section B. Individual(s) Conducting

Cash In $11,000 and no entry for Cash Out. This

Negotiable Instrument(s) Cashed would be

Transaction(s) (if other than above).—Financial

is because the $3,000 transaction does not meet

indicated, but no account at the financial

institutions should enter as much information as

the reporting threshold.

institution has been affected. Therefore, item 35

is available. However, there may be instances in

should be left BLANK.

Example 2: A person deposts $11,000 in

which Items 15-25 may be left BLANK or

currency to his savings account and withdraws

Item 36. Other (specify).—If a transaction is not

incomplete.

$12,000 in currency from his checking account.

identified in Items 30–34, check Item 36 and

If Items 15-25 are left BLANK or incomplete,

provide an additional description. For example, a

The CTR should be completed as follows:

check one or more of the boxes provided to

person presents a check to purchase “foreign

Cash In $11,000, Cash Out $12,000. This is

indicate the reason(s).

currency”.

because there are two reportable transactions.

Example: If there are multiple transactions that,

However, one CTR may be filed to reflect both.

if only when aggregated, the financial institution

Part III - Financial Institution

Example 3: A person deposits $6,000 in

has knowledge the transactions exceed the

Where Transaction(s) Takes Place

currency to his savings account and withdraws

reporting threshold, and therefore, did not

$4,000 in currency from his checking account.

Item 37. Name of Financial Institution and

identify the transactor(s), check box d for

Further, he presents $5,000 in currency to be

Identity of Federal Regulator or BSA

Multiple Transactions.

exchanged for the equivalent in French francs.

Examiner.—Enter the financial institution’s full

Items 15, 16, and 17. Individual(s)

legal name and identify the federal regulator or

The CTR should be completed as follows:

Name.—Complete these items if an

BSA examiner, using the following codes:

Cash In $11,000 and no entry for Cash Out. This

individual conducts a transaction(s) on behalf

is because in determining whether the

of another person. For example, if John

FEDERAL REGULATOR

transactions are reportable, the currency

Doe, an employee of XYZ Grocery Store

OR BSA EXAMINER

CODE

exchange is aggregated with each of the Cash In

makes a deposit to the store’s account,

and the Cash Out amounts. The result is a

Comptroller of the Currency (OCC)

XYZ Grocery Store should be identified in

reportable $11,000 Cash In transaction. The total

Section A, and John Doe should be

Federal Deposit Insurance Corporation (FDIC)

Cash Out amount is $9,000 which does not

identified in Section B.

Federal Reserve System (FRS)

meet the reporting threshold; therefore, it is not

Items 18, 20, 21, 22, and 23. Address.—Enter

Office of Thrift Supervision (OTS)

entered on the CTR.

the permanent street address including zip code

National Credit Union Administration (NCUA)

Example 4: A person deposits $6,000 in

of the individual. (See Items 7, 9, 10, 11, and

currency to his savings account and withdraws

12.)

Securities and Exchange Commission (SEC)

$7,000 in currency from his checking acount.

Item 19. SSN.—If the individual has an SSN,

Internal Revenue Service (IRS)

Further, he presents $5,000 in currency to be

enter it in Item 19. If the individual does not have

U.S. Postal Service (USPS)

exchanged for the equivalent in French francs.

an SSN, enter NONE.

The CTR should be completed as follows:

Items 38, 40, 41, and 42. Address.—Enter the

Item 24. Date of Birth.—Enter the individual’s

Cash In $11,000, Cash Out $12,000. This is

street address, city, state, and ZIP code of the

date of birth. See the instructions for item 8.

because in determining whether the transactions

financial institution where the transaction

Item 25. If an Individual, Describe Method

are reportable, the currency exchange is

occurred. If there are multiple transactions,

Used To Verify.—Enter the method by which the

aggregated with each of the Cash In and Cash

provide information on the office or branch

individual’s identity is verified (see General

Out amounts. In this example, each of the Cash

where any one of the transactions has occurred.

Instructions and Item 14).

In and Cash Out totals exceed $10,000 and

Item 39. EIN or SSN.—Enter the financial

must be reflected on the CTR.

PART II - Amount and Type of

institution’s EIN. If the financial institution does

Item 29. Foreign Currency.—If foreign currency

not have an EIN, enter the SSN of the financial

Transaction(s)

is involved, check Item 29 and identify the

institution’s principal owner.

Complete Part II to Identify the type of

country. If multiple foreign currencies are

Item 43. MICR Number.—If a depository

transaction(s) reported and the amount(s)

involved, identify the country for which the

institution, enter the Magnetic Ink Character

involved.

largest amount is exchanged.

Recognition (MICR) number.

Items 26 and 27. Cash In/Cash Out.—In the

Items 30-33.—Check the appropriate item(s) to

spaces provided, enter the amount of currency

identify the following type of transaction(s):

Signature

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

30. Wire Transfer(s)

Items 44 and 45. Title and Signature of

the financial institution. If foreign currency is

31. Negotiable Instrument(s) Purchased

Approving Official.—The official who reviews

exchanged, use the U.S. dollar equivalent on the

and approves the CTR must indicate his/her title

32. Negotiable Instrument(s) Cashed

day of the transaction.

and sign the CTR.

33. Currency Exchange(s)

If less than a full dollar amount is involved,

Item 46. Date the Form Was Signed.—The

increase that figure to the next highest dollar.

Item 34. Deposits/Withdrawals.—Check this

approving official must enter the date the CTR is

For example, if the currency totals $20,000.05,

item to identify deposits to or withdrawals from

signed. (See Item 8.)

show the total as $20,001.00.

accounts, e.g., demand deposit accounts,

Item 47. Preparer’s Name.—Type or print the

savings accounts, time deposits, mutual fund

Item 28. Date of Transaction.—Six numerals

full name of the individual preparing the CTR.

accounts or any other account held at the

must be inserted for each date. (See Item 8.)

The preparer and the approving official may not

financial institution. Enter the account number(s)

necessarily be the same individual.

Determining Whether Transactions

in item 35.

Items 48 and 49. Contact Person/Telephone

Meet the Reporting Threshold

Item 35. Account Numbers Affected (if any).—

Number.—Type or print the name and telephone

Enter the account numbers of any accounts

Only cash transactions that, if alone or when

number of an individual to contact concerning

affected by the transaction(s) that are maintained

aggregated, exceed $10,000 should be reported

questions about the CTR.

on the CTR. Transactions shall not be offset

against one another.

Printed on recycled paper

Currency Transaction Report - Form 4789 Page 4

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