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Currency Transaction Report (IRS)

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Currency Transaction Report
OMB No. 1506-0004
FINCEN Form 104
(March 2011)
(Complete all parts that apply--See Instructions)
1 Check all box(es) that apply:
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
5 Doing business as (DBA)
4 Middle initial3 First name
2 Individual’s last name or entity’s name
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
Department of the Treasury
FinCEN
9 City
10 State 11 ZIP code
12 Country code
(if not U.S.)
13 Occupation, profession, or business
25 If an individual, describe method used to verify identity:
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)
14 If an individual, describe method used to verify identity:
44 Title of approving official
47 Type or print preparer’s name
45 Signature of approving official
48 Type or print name of person to contact
49 Telephone number
18 Address (number, street, and apt. or suite no.)
17 Middle initial16 First name
15 Individual’s last name
19 SSN
20 City
21 State 22 ZIP code
23 Country code
(If not U.S.)
40 City
38 Address (number, street, and apt. or suite no.)
Enter Regulator or BSA
Examiner code number
(see instructions)
37 Name of financial institution
42 ZIP code 43 Routing (MICR) number41 State
26 Total cash in $ .00
Cat. No. 37683N
FinCEN Form 104 (Rev. 03-2011)
Previous editions will not be accepted after September, 2011.
Please type or print.
Person(s) Involved in Transaction(s)
Part I
b Mail Deposit or Shipment c Night Deposit or Automated Teller Machine d Multiple Transactions
a Armored Car Service
8 Date of birth
____/____/_______
MM DD YYYY
24 Date of birth
____/____/_______
MM DD YYYY
b Passport c Alien registration
d Other
f Number:
Amount and Type of Transaction(s). Check all boxes that apply.
28 Date of transaction
____/____/_______
MM DD YYYY
26a Foreign cash in .00
27 Total cash out $ .00
27a Foreign cash out .00
30 Wire Transfer(s)
31 Negotiable Instrument(s) Purchased
34 Deposit(s)/Withdrawal(s)
35 Account Number(s) Affected (if any): 36 Other (specify)
Part III
Financial Institution Where Transaction(s) Takes Place
39 EIN or SSN
For Paperwork Reduction Act Notice, see page 4.
Sign
Here
____/____/_______
MM DD YYYY
(
)
46 Date of signature
a Amends prior report b Multiple persons c Multiple transactions
e Issued by:
33 Currency Exchange(s)
d Other
b Passport
c Alien registration
a Driver’s license/State I.D.
f Number:
e Issued by:
e Conducted On Own Behalf
a Driver’s license/State I.D.
(see instructions, page 4)
32 Negotiable Instrument(s) Cashed
29 Foreign Country
(see instructions, page 4)
Part II
0
0
0
0
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
5 Doing business as (DBA)
4 Middle initial3 First name
2 Individual’s last name or entity’s name
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
9 City 10 State 11 ZIP code
12 Country code
(if not U.S.)
25 If an individual, describe method used to verify identity:
Section B--Individual(s) Conducting Transaction(s) (if other than above).
14 If an individual, describe method used to verify identity:
f Number:
e Issued by:
18 Address (number, street, and apt. or suite no.)
17 Middle initial
16 First name
15 Individual’s last name
19 SSN
20 City 21 State 22 ZIP code
23 Country code
(if not U.S.)
Person(s) Involved in T ransaction(s)
Part I
8 Date of birth
____/____/_______
MM DD YYYY
24 Date of birth
____/____/_______
MM DD YYYY
a Driver’s license/State I.D.
b Passport c Alien registration
d Other
e Issued by:
f Number:
Multiple Persons
Complete applicable parts below if box 1b on page 1 is checked
FinCEN Form 104 (Eff. 03-2011) Page 2
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
5 Doing business as (DBA)
4 Middle initial3 First name
2 Individual’s last name or entity’s name
6 SSN or EIN
7 Address (number, street, and apt. or suite no.)
9 City
10 State 11 ZIP code
12 Country code
(if not U.S.)
25 If an individual, describe method used to verify identity:
Section B--Individual(s) Conducting Transaction(s) (if other than above).
14 If an individual, describe method used to verify identity:
f Number:
18 Address (number, street, and apt. or suite no.)
17 Middle initial
16 First name
15 Individual’s last name
19 SSN
20 City
21 State 22 ZIP code
23 Country code
(if not U.S.)
Person(s) Involved in T ransaction(s)
Part I
8 Date of birth
____/____/_______
MM DD YYYY
24 Date of birth
____/____/_______
MM DD YYYY
a Driver’s license/State I.D. b Passport c Alien registration
a Driver’s license/State I.D.
b Passport
c Alien registration
d Other
a Driver’s license/State I.D.
b Passport
c Alien registration
e Issued by:
d Other
f Number:
e Issued by:
d Other
13 Occupation, profession, or business
13 Occupation, profession, or business
FinCEN Form 104 (Eff. 03-2011)
Page 3
Suspicious Transactions
This Currency Transaction Report (CTR) should NOT be
filed for suspicious transactions involving $10,000 or less
in currency OR to note that a transaction of more than
$10,000 is suspicious. Any suspicious or unusual activity
should be reported by a financial institution in the manner
prescribed by its appropriate federal regulator or BSA
examiner. (See the instructions for Item 37). If a transaction
is suspicious and in excess of $10,000 in currency, then
both a CTR and the appropriate Suspicious Activity Report
form must be filed.
In situations involving suspicious transactions requiring
immediate attention, such as when a reportable transaction
is ongoing, the fianacial institution shall immediately notify
,
by telephone, appropriate law enforcement and regulatory
authorities in addition to filing a timely suspicious activity
report.
General Instructions
Who Must File. Each financial institution (other than a
casino, which instead must file FinCEN Form 103, and the
U.S. Postal Service for which there are separate rules) must
file FinCEN Form 104 (CTR) for each deposit, withdrawal,
exchange of currency
, or other payment or transfer, by,
through, or to the financial institution which involves a
transaction in currency of more than $10,000. Multiple
transactions must be treated as a single transaction if the
financial institution has knowledge that (1) they are by or
on behalf of the same person, and (2) they result in either
currency received (Cash In) or currency disbursed (Cash
Out) by the financial institution totaling more than $10,000
during any one business day. For a bank, a business day is
the day on which transactions are routinely posted to
customers’ accounts, as normally communicated to
depository customers. For all other financial institutions,
a business day is a calendar day.
Generally, financial institutions are defined as banks, other
types of depository institutions, brokers or dealers in
securities, money transmitters, currency exchangers, check
cashers, and issuers and sellers of money orders and traveler’s
checks. Should you have questions, see the definitions in
31 CFR Chapter X.
When and Where To File. This form should be e-filed
through the Bank Secrecy Act E-filing System. Go to
http: //bsaefiling.fincen.treas.gov/index.jsp to register.
This form is also available for download on the Financial
Crimes Enforcement Network’s Web site at www.fincen.gov,
or may be ordered by calling the IRS Forms Distribution
Center at (800) 829-3676. File this CTR by the 15th
calendar day after the day of the transaction with the:
Enterprise Computing Center - Detroit
ATTN: CTR
P.O. Box 33604
Detroit, MI 48232-5604
Keep a copy of each CTR for five years from the date filed.
A financial institution may apply to file the CTRs
electronically. To obtain an application to file
electronically, contact the Bank Secrecy Act E-filing
System. Go to http: //bsaefiling.fincen.treas.gov/
main.html to register or contact the
BSA E-Filing Help
Desk at 1-866-346-9478 (select option # 6) or via email
at
BSAEFilingHelp@fincen.gov
Identification Requirements. All individuals (except a
employees of armored car services) conducting a reportable
transaction(s) for themselves or for another person, must be
identified by means of an official
document(s).
Acceptable forms of identification include
driver’s license, military and military/dependent
identification cards, passport, state issued identification
card, cedular card (foreign), non-resident alien identification
cards, or any other identification document
or documents, which contain name and preferably address
and a photograph and are normally acceptable by financial
institutions as a means of identification when cashing checks
for persons other than established customers.
Acceptable identification information obtained previously
and maintained in the financial institution’s records may be
used. For example, if documents verifying an individual’s
identity were examined and recorded on a signature card
when an account was opened, the financial institution may
rely on that information. In completing the CTR, the
financial institution must indicate on the form the method,
type, and number of the identification. Statements such as
“known customer” or “signature card on file” are not
sufficient for form completion.
Penalties. Civil and criminal penalties are provided for
failure to file a CTR or to supply information or for filing a
false or fraudulent CTR. See 31 U.S.C. 5321, 5322 and
5324.
For purposes of this CTR, the terms below have the
following meanings:
Currency. The coin and paper money of the United States
or any other country, which is circulated and customarily
used and accepted as money.
Person. An individual, corporation, partnership, trust or
estate, joint stock company, association, syndicate, joint
venture or other unincorporated organization or group.
Organization. Entity other than an individual.
Transaction in Currency. The physical transfer of currency
from one person to another. This does not include a transfer
of funds by means of bank check, bank draft, wire transfer or
other written order that does not involve the physical transfer
of currency.
Negotiable Instruments. All checks and drafts (including
business, personal, bank, cashier’s and third-party), money
orders, and promissory notes. For purposes of this CTR,
all traveler’s checks shall also be considered negotiable
instruments whether or not they are in bearer form.
Foreign exchange rate. If foreign currency is a part of a
currency transaction that requires the completion of a
CTR, use the exchange rate in effect for the business day
of the transaction to compute the amount, in US dollars,
to enter in item 26/27. The source of the exchange rate that
is used will be determined by the reporting institution.
Specific Instructions
Because of the limited space on the front and back of the
CTR, it may be necessary to submit additional information
on attached sheets. Submit this additional information on
plain paper attached to the CTR. Be sure to put the
individual’
s or entity’s name and identifying number (items
2, 3, 4, and 6 of the CTR) on any additional sheets so that
if it becomes separated, it may be associated with the CTR.
Item 1a. Amends Prior Report. If this CTR is being
filed because it amends a report filed previously
, check
Item 1a. Complete the form in its entirety (Part I, II,
and III) and include the amended information. Do not
attach a copy of the original.
Multiple Persons. If this transaction is being conducted
by more than one person or on behalf of more than one
person, check Item 1b. Enter information in Part I for one
of the persons and provide information on any other
persons on the back of the CTR.
Item 1c. Multiple
Transactions. If the financial institution
has knowledge that there are multiple transactions, check
Item 1c.
PART I - Person(s) Involved in Transaction(s)
Section A must be completed. If an individual conducts a
transaction on his own behalf, complete Section A and
leave Section “B” BLANK. If an individual conducts a
transaction on his own behalf and on behalf of another
person(s), complete Section “A” for each person and leave
Section “B” BLANK. If an individual conducts a
transaction on behalf of another person(s), complete Section
“B” for the individual conducting the transaction, and
complete Section “A” for each person on whose behalf the
transaction is conducted of whom the financial institution
has knowledge.
Section A. Person(s) on Whose Behalf Transaction(s)
Is Conducted. See instructions above.
Items 2, 3, and 4. Individual/Organization Name. If
the person on whose behalf the transaction(s) is conducted
is an individual, put his/her last name in Item 2, first name
in Item 3, and middle initial in Item 4. If there is no
middle initial, leave item 4 BLANK. If the transaction is
conducted on behalf of an entity, enter the name in Item 2
and leave Items 3 and 4 BLANK.
Item 5. Doing Business As (DBA). If the financial
institution has knowledge of a separate “doing business
as” name, enter it in Item 5. For example, if Smith
Enterprise is doing business as MJ’s Pizza, enter “MJ’s
Pizza” in item 5.
Item 6. SSN or EIN. Enter the Social Security Number
(SSN) or Individual Taxpayer Identification Number (ITIN)
or Employer Identification Number (EIN) of the person or
entity identified in Item 2. If none, leave blank.
Items 7, 9, 10, 11, and 12. Address. Enter the permanent
address including ZIP Code of the person identified in Item
2. Use the U.S. Postal Service’s two letter state abbreviation
code. A P. O. Box should not be used by itself, and may
only be used if there is no street address. If a P. O. Box is
used, the name of the apartment or suite number, road or
route number where the person resides must also be provided.
If the address is outside the U.S., provide the street address,
city, province or state, postal code (if known), and the two
letter country code. For country code list go to
www.fincen.gov/reg_bsaforms.html or telephone 800-949-
2732 and select option number 5. If U.S., leave item 12
blank.
Item 8. Date of Birth. Enter the date of birth. Eight
numerals must be inserted for each date. The first two will
reflect the month, the second two the day, and the last four
the year. A zero (0) should precede any single digit number.
For example, if an individual’s birth date is April 3 1948,
Item 8 should read 04 03 1948.
Item 13.
Occupation, profession, or business. If known,
identify the occupation, profession or business that best
describes the individual or entity in Part I (e.g., attorney,
car dealer, carpenter, doctor, farmer, plumber, truck driver,
etc.). Do not use nondescript terms such as businessman,
merchant, store owner (unless store’s name is provided), or
self employed. If unemployed, or retired are used enter the
regular or former occupation if known.
Item 14. If an Individual, Describe Method Used To
Verify Identity. If an individual conducts the transaction(s)
on his/her own behalf, his/her identity must be verified by
examination of an acceptable document (see General
Instructions). For example, check box a if a driver’s license
is used to verify an individual’s identity, and enter the state
that issued the license and the number in items e and f. If
the transaction is conducted by an individual on behalf of
another individual not present, or on behalf of an entity,
check box “14d” “Other” and enter “NA” on the line
provided.
FinCEN Form 104 (Eff. 03-2011)
Page 4
Section B. Individual(s) Conducting Transaction(s)
(if other than above). Financial institutions should enter
as much information as is available.
However, there may
be instances in which Items 15-25 may be left BLANK or
incomplete. If Items 15-25 are left BLANK or incomplete,
check one or more of the boxes provided to indicate the
reasons.
Example: If there are multiple transactions that, if only
when aggregated, the financial institution has knowledge
the transactions exceed the reporting threshold, and therefore,
did not identify the transactor(s), check box d for Multiple
Transactions.
Items 15, 16, and 17. Individual’s Name. Complete
these items if an individual conducts a transaction(s) on
behalf of another person. For example, if John Doe, an
employee of XY Grocery Store, makes a deposit to the
store’s account, XY Grocery Store should be identified in
Section A and John Doe should be identified in section B.
Items 18, 20, 21, 22, and 23. Address. Enter the permanent
street address including ZIP Code of the individual. (See
the instructions for Items 7 and 9 through 12.) Enter country
code if not U.S. (Reference item 12).
Item 19. SSN/ITIN. If the individual has a Social Security
Number, or Individual Taxpayer Indentifcation Number ,
enter it in Item 19. If the individual does not have an SSN/
ITIN, enter NONE.
Item 24. Date of Birth. Enter the individual’ s date of
birth. (See the instructions for Item 8.)
Item 25. If an Individual, Describe Method Used To
Verify Identity. Enter the method used to identify the
individual’s identity. (See General Instructions and the
instructions for Item 14.)
PART II - Amount and Type of Transaction(s)
Complete Part II to identify the type of transaction(s) and
the amount(s) involved.
Items 26 and 27. Total Cash In/Total Cash Out. In the
spaces provided, enter the total amount of currency received
(Total Cash In) or total currency disbursed (T otal Cash
Out) by the financial institution. If foreign currency is
exchanged, use the U.S. dollar equivalent on the day of the
transaction (See “Foreign exchange rates”), and complete
item 26a or 27a, whichever is appropriate.
If less than a full dollar amount is involved, increase that
figure to the next highest dollar. For example, if the currency
totals $20,000.05, show the total as $20,001.00.
Items 26a and 27a. Foreign cash in/Foreign cash out. If
foreign currency is exchanged, enter the amount of foreign
currency (Do not convert to U.S. dollars) in items 26a and
27a. Report country of origin in item 29.
Item 28. Date of Transaction. Insert eight numerals for
each date. (See instructions for Item 8.)
Item 29. Foreign Country. If items 26a and/or 27a are
completed indicating that foreign currency is involved,
check Item 29 and identify the country. If multiple foreign
currencies are involved, check box 36 and identify the
additional country(s) and/or currency(s) involved.
Determining Whether Transactions Meet the
Reporting Threshold.
Only cash transactions that, if alone or when aggregated,
exceed $10,000 should be reported on the CTR.
Transactions shall not be offset against one another.
If there are both Cash In and Cash Out transactions that are
reportable, the amounts should be considered separately
and not aggregated. However, they may be reported on a
single CTR.
If there is a currency exchange, it should be aggregated
separately with each of the Cash In and Cash Out totals.
Example 1: A person deposits $11,000 in currency to his
savings account and withdraws $3,000 in currency from
his checking account. The CTR should be completed as
follows:
Cash In $11,000 and no entry for Cash Out. This is
because the $3,000 transaction does not meet the reporting
threshold.
Example 2: A person deposits $11,000 in currency to his
savings account and withdraws $12,000 in currency from
his checking account. The CTR should be completed as
follows:
Cash In $11,000, Cash Out $12,000. This is because
there are two reportable transactions. However, one CTR
may be filed to reflect both.
Example 3: A person deposits $6,000 in currency to his
savings account and withdraws $4,000 in currency from
his checking account. Further, he presents $5,000 in
currency to be exchanged for the equivalent in Euro’s. The
CTR should be completed as follows:
Cash In $11,000 and no entry for Cash Out. This is
because in determining whether the transactions are
reportable, the currency exchange is aggregated with each
of the Cash In and Cash Out amounts. The result is a
reportable $11,000 Cash In transaction. The total Cash
Out amount is $9,000, which does not meet the reporting
threshold. Therefore, it is not entered on the CTR.
Example 4: A person deposits $6,000 in currency to his
savings account and withdraws $7,000 in currency from
his checking account. Further, he presents $5,000 in
currency to be exchanged for the equivalent in Euro’s. The
CTR should be completed as follows:
Cash In $11,000, Cash Out $12,000. This is because in
determining whether the transactions are reportable, the
currency exchange is aggregated with each of the Cash In
and Cash Out amounts. In this example, each of the Cash
In and Cash Out totals exceed $10,000 and must be reflected
on the CTR.
Items 30-33. Check the appropriate item(s) to identify the
following type of transaction(s):
30. Wire Transfer(s)
31. Negotiable Instrument(s) Purchased
32. Negotiable Instrument(s) Cashed
33. Currency Exchange(s)
Item 34. Deposits/Withdrawals. Check this item to
identify deposits to or withdrawals from accounts, e.g.
demand deposit accounts, savings accounts, time deposits,
mutual fund accounts, or any other account held at the
financial institution. Enter the account number(s) in Item
35.
Item 35. Account Numbers Affected (if any). Enter the
account numbers of any accounts affected by the transactions
that are maintained at the financial institution conducting
the transaction(s).
Example 1: If a person cashes a check drawn on an
account held at the financial institution, the CTR should
be completed as follows:
Indicate negotiable instrument(s) cashed and provide the
account number of the check.
If the transaction does not affect an account, make no entry.
Example 2: A person cashes a check drawn on another
financial institution. In this instance, negotiable
instrument(s) cashed would be indicated, but no account at
the financial institution has been affected. Therefore, Item
35 should be left BLANK.
Item 36. Other (specify). If a transaction is not identified
in Items 30-34, check Item 36 and provide an additional
description. For example, a person presents a check to
purchase “foreign currency.” If multiple (more than one)
foreign currencies are involved in the transaction, enter the
amount of the largest foreign currency transaction in item
26a or 27a and that currency’ s country-code of origin in
item 29. Then check box 36 and enter the additional
foreign currencies amount(s) and country-code(s) of origin
in the space provided.
PAR
T III - Financial Institution Where Transaction(s)
Take Place
Item 37. Name of Financial Institution and Identity of
Regulator or BSA Examiner. Enter the financial
institution’s full legal name and identify the regulator or
BSA examiner, using the following codes:
Regulator or BSA Examiner
CODE
Comptroller of the Currency (OCC).........................1
Federal Deposit Insurance Corporation (FDIC)...........2
Federal Reserve System (FRS)................................3
Office of Thrift Supervision (OTS)...........................4
National Credit Union Administration (NCUA)..........5
Securities and Exchange Commission (SEC).............6
Internal Revenue Service (IRS)................................7
U.S. Postal Service (USPS)....................................8
Commodity Futures Trading Commission (CFTC).....9
State Regulator.....................................................10
Items 38, 40, 41, and 42. Address. Enter the street
address, city, state, and ZIP Code of the financial institution
where the transaction occurred. If there are multiple
transactions, provide information of the office or branch
where any one of the transactions has occurred.
Item 39. EIN or SSN. Enter the financial institution’ s
EIN. If the financial institution does not have an EIN, enter
the SSN of the financial institution’ s principal owner.
Item 43. Routing (MICR) Number. If a depository
institution, enter the routing (Magnetic Ink Character
Recognition (MICR)) number .
SIGNATURE
Items 44 and 45. Title and signature of Approving
Official. The official who reviews and approves the CTR
must indicate his/her title and sign the CTR.
Item 46. Date of Signature. The approving official must
enter the date the CTR is signed. (See the instructions for
Item 8.)
Item 47. Preparer’s Name. Type or print the full name of
the individual preparing the CTR. The preparer and the
approving official may not necessarily be the same
individual.
Items 48 and 49. Contact Person/Telephone Number.
Type or print the name and telephone number of an
individual to contact concerning questions about the CTR.
Paperwork Reduction Act Notice. The requested information
is useful in criminal, tax, and regulatory investigations and
proceedings. Financial institutions are required to provide
the information under 31 U.S.C. 5313 and 31 CFR Chapter X,
commonly referred to as the Bank Secrecy Act (BSA). The BSA
is administered by the U.S. Department of the Treasury’s
Financial Crimes Enforcement Network (FinCEN). You are
not required to provide the requested information unless a form
displays a valid OMB control number. The time needed to
complete this form will vary depending on individual
circumstances. The estimated average time is 19 minutes. If you
have comments concerning the accuracy of this time estimate or
suggestions for making this form simpler, you may write to the
Financial Crimes Enforcement Network, P. O. Box 39,
Vienna, VA 22183. Do not send this form to this office. Instead,
see When and Where to File in the instructions.
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Currency Transaction Report (IRS)

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Completed 7 November 2020

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