Form 4790 (031695) Report Of International Transportation Of Currency Or Monetary Instruments printable pdf download

Form Approved

OMB No. 1515-0079

DEPARTMENT OF THE TREASURY

UNITED STATES CUSTOMS SERVICE

(U.S. Customs Use Only)

This form is to be filed with the

United States Customs Service

REPORT OF INTERNATIONAL

Control No.

For Paperwork Reduction Act

TRANSPORTATION OF CURRENCY

31 U.S.C. 5316; 31 CFR 103.23 and 103.25

Notice and Privacy Act Notice,

OR MONETARY INSTRUMENTS

Please type or print.

see back of form.

Part I

FOR INDIVIDUAL DEPARTING FROM OR ENTERING THE UNITED STATES

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

2. IDENTIFYING NO. (See instructions)

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

4. PERMANENT ADDRESS IN UNITED STATES OR ABROAD

5. OF WHAT COUNTRY ARE YOU A

CITIZEN/SUBJECT?

6. ADDRESS WHILE IN THE UNITED STATES

7. PASSPORT NO. & COUNTRY

8. U.S. VISA DATE

9. PLACE UNITED STATES VISA WAS ISSUED

10. IMMIGRATION ALIEN NO. (If any)

11. CURRENCY OR MONETARY INSTRUMENT WAS: (Complete 11A or 11B)

A. EXPORTED

B. IMPORTED

Departed From: (City in U.S.)

Arrived At: (Foreign City/Country)

From: (Foreign City/Country)

At: (City in U.S.)

Part II

FOR PERSON SHIPPING, MAILING, OR RECEIVING CURRENCY OR MONETARY INSTRUMENTS

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

13. IDENTIFYING NO. (See instructions)

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

15. PERMANENT ADDRESS IN UNITED STATES OR ABROAD

16. OF WHAT COUNTRY ARE YOU

A CITIZEN/SUBJECT?

17. ADDRESS WHILE IN THE UNITED STATES

18. PASSPORT NO. & COUNTRY

19. U.S. VISA DATE

20. PLACE UNITED STATES VISA WAS ISSUED

21. IMMIGRATION ALIEN NO. (If any)

23. CURRENCY OR

NAME AND ADDRESS

22. CURRENCY OR

24. IF THE CURRENCY OR MONETARY INSTRUMENT WAS

MONETARY

MAILED,

SHIPPED,

TRANSPORTED

COMPLETE

INSTRUMENTS

BLOCKS A AND B.

INSTRUMENTS

DATE SHIPPED

A. Method of Shipment (Auto, U.S. Mail, Public Carrier, etc.)

Shipped

DATE RECEIVED

B. Name of Transporter/Carrier

Received

From

Part III

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

25. TYPE AND AMOUNT OF CURRENCY/MONETARY INSTRUMENTS

Value in U.S. Dollars

26. IF OTHER THAN U.S. CURRENCY

INVOLVED,

PLEASE

COMPLETE

BLOCKS A AND B. (SEE SPECIAL

Coins

INSTRUCTIONS)

A. Currency Name

Currency

Other Instruments (Specify Type)

B. Country

TOTAL

(Add lines A, B and C)

AMOUNT

Part IV

GENERAL - TO BE COMPLETED BY ALL TRAVELERS, SHIPPERS, AND RECIPIENTS

27. WERE YOU ACTING AS AN AGENT, ATTORNEY OR IN CAPACITY FOR ANYONE IN THIS

Yes

CURRENCY OR MONETARY INSTRUMENT ACTIVITY? (If "Yes" complete A, B and C)

A. Name

B. Address

C. Business activity, occupation, or profession

PERSON

WHOSE

BE-

HALF

YOU

ARE ACTING

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.

28. NAME AND TITLE

29. SIGNATURE

30. DATE

(Replaces IRS Form 4790 which is obsolete.)

Customs Form 4790 (031695)

Form 4790 (031695) Report Of International Transportation Of Currency Or Monetary Instruments

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