Fillable FinCEN FORM 104 (Rev. 12-2003)

FINCEN Form 104 a Currency Transaction Report Previous editions will not be accepted after September, 2011. Please type or print. (Complete all parts that apply--See Instructions) OMB No. 1506-0004 (March 2011) Department of the Treasury FinCEN 1 Check all box(es) that apply: Amends prior report b Multiple persons c Multiple transactions Part I Person(s) Involved in Transaction(s) 3 First name 6 SSN or EIN 8 Date of birth 4 Middle initial Section A--Person(s) on Whose Behalf Transaction(s) More

This Currency Transaction Report (CTR) should NOT be filed for suspicious ... both a CTR and the appropriate Suspicious Activity Report form must be filed. Less