Fillable Occ2003-48a Draft CTR(4.15.03) 4789

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Occ2003-48a Draft CTR(4.15.03) 4789

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Currency Transaction Report
OMB No. 1506-0004
FINCEN Form 104
(Formerly Form 4789)
(Rev. August 2003)
(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) number
41 State
26 Total cash in $ .00
Cat. No. 42004W
FinCEN Form 104 (Formerly Form 4789) (Rev. 8-03)
Previous editions will not be accepted after August 31, 2004.
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:
Part II
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 3)
32 Negotiable Instrument(s) Cashed
29 Foreign Country
(see instructions, page 3)
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 Transaction(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 (formerly Form 4789) (Rev. 8-03) 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 Transaction(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 (Formerly Form 4789 (Rev. 8-03)
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.
Should the suspicious activity require immediate
attention, financial institutions should telephone
1-800-800-CTRS. An Internal Revenue Service (IRS)
employee will direct the call to the local office of the
IRS Criminal Investigation Division (CI). This toll-free
number is operational Monday through Friday, from
approximately 9:00 am to 6:00 pm Eastern Standard
Time. If an emergency, consult directory assistance for
the local IRS CID Office.
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 (formerly 4789) (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 Part 103.
When and Where To File. File this CTR by the 15th
calendar day after the day of the transaction with the:
IRS Detroit Computing Center
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
magnetically. To obtain an application to file magnetically,
write to the:
IRS Detroit Computing Center
ATTN: CTR Magnetic Media Coordinator
P.O. Box 33604
Detroit, MI 48232-5604
Identification Requirements. All individuals (except
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
a 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 rates. If completing items 26a/27a,
use the exchange rate in effect for the business day of
the transaction. 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. Staple a copy of the original CTR to the
amended one, complete Part III fully and only those other
entries which are being amended.
Item 1b. 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, put its
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, Smith Enterprise DBA MJ’s Pizza.
Item 6. SSN/ITIN 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,
write NONE.
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 or telephone
1-800-949-2732 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. Identify
the occupation, profession, or business of the person on
whose behalf the transaction was conducted. For
example: secretary, shoe salesman, carpenter, attorney,
housewife, restaurant, liquor store,etc. Do not use non-
specific terms such as merchant, self-employed,
businessman, etc.
Item 14. If an Individual, Describe Method Used To
Verify Identify. 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, enter N/A in Item 14.
Section B. Individual(s) Conducting Transaction(s)(if
other than above). Financial institutions should enter as
much information as is available.
FinCEN Form 104 (Formerly 4789 (Rev. 8-03)
Page 4
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 XYZ Grocery Store, makes a deposit to the
store’s account, XYZ 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 Identify. Enter the method used to identify the
individual’s identy. (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 (Total
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 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 Currency. 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 French
Francs. 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 French
francs. 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). If necessary,
use additional sheets of paper to indicate all of the
affected accounts.
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.” Also list multiple foreign
currencies from item 29.
PART 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
F
ederal 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 Part 103, 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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