Form 104 - Currency Transaction Report Form - 2011
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1
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4Currency Transaction Report
104
FINCEN Form
Previous editions will not be accepted after September, 2011.
(March 2011)
Please type or print.
Department of the Treasury
(Complete all parts that apply--See Instructions)
FinCEN
OMB No. 1506-0004
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 entity’s name
3 First name
4 Middle initial
5 Doing business as (DBA)
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
8 Date of birth
____/____/_______
MM
DD
YYYY
10 State 11 ZIP code
12 Country code
9 City
13 Occupation, profession, or business
(if not U.S.)
14 If an individual, describe method used to verify identity:
b
Passport
a
Driver’s license/State I.D.
c
Alien registration
e Issued by:
d
Other
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)
b
Mail Deposit or Shipment
c
Night Deposit or Automated Teller Machine
d
Multiple Transactions
e
Conducted On Own Behalf
a
Armored Car Service
15 Individual’s last name
16 First name
17 Middle initial
18 Address (number, street, and apt. or suite no.)
19 SSN
20 City
21 State
22 ZIP code
24 Date of birth
23 Country code
____/____/_______
(If not U.S.)
MM
DD
YYYY
25 If an individual, describe method used to verify identity:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
e Issued by:
f Number:
d
Other
Part II
Amount and Type of Transaction(s). Check all boxes that apply.
28 Date of transaction
0
0
26
Total cash in $
.00
____/____/_______
27
Total cash out $
.00
MM
DD
YYYY
0
0
26a
Foreign cash in
.00
27a Foreign cash out
.00
(see instructions, page 4)
(see instructions, page 4)
29
Foreign Country
30
Wire Transfer(s)
31
Negotiable Instrument(s) Purchased
34
Deposit(s)/Withdrawal(s)
33
Currency Exchange(s)
32
Negotiable Instrument(s) Cashed
35
Account Number(s) Affected (if any):
36
Other (specify)
Part III
Financial Institution Where Transaction(s) Takes Place
Enter Regulator or BSA
37 Name of financial institution
Examiner code number
(see instructions)
38 Address (number, street, and apt. or suite no.)
39 EIN or SSN
41 State
42 ZIP code
43 Routing (MICR) number
40 City
44 Title of approving official
45 Signature of approving official
46 Date of signature
____/____/_______
Sign
MM
DD
YYYY
47 Type or print preparer’s name
48 Type or print name of person to contact
49 Telephone number
Here
(
)
FinCEN Form 104 (Rev. 03-2011)
For Paperwork Reduction Act Notice, see page 4.
Cat. No. 37683N
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