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This report is required by Treasury Department regulations (31 Code of Federal Regulations 103).
Who Must File.-- Beginning July 1, 1972, each financial institution (as described in these instructions) shall file a report of each deposit, withdrawal, exchange of currency or other payment or transfer, by, through, or to such financial institution, which involves a transaction in currency of more than $10,000.
Exceptions.--Financial institutions are not required to file Form 4789 for transactions: (1) with Federal Reserve Banks or Federal Home Loan
Banks; (2) solely with, or originated by, financial institutions or
foreign banks; or (3) between a bank and established customers maintain. - ing deposit relationship with the bank, in amounts
which the bank may reasonably conclude do not exceed amounts commensurate with the customary conduct of
the customer's business, industry or profession. However, upon request each bank shall submit a report listing those customers who engage in transactions which were not reported because of the exemption in (3).
When and Where to File-This report shall be filed on or before the 45th day following the date of the transaction with the Internal Revenue Service Center, 11601 Roosevelt Boulevard, Philadelphia, Pennsylvania 19155. Forms may be obtained from any Internal Revenue Service office.
identifying Number.Social security number or employer, identification number it other than individual.
Identification Required.-Before any transaction is effected a financial institution shall verify and record the identity, and record the account number on its books or the social security or taxpayer identification number, if any, of a person with whom or for whose account such transaction is to be effected. Verification of identity for a customer of the financial institution depositing or withdrawing funds may be by reference to his account or other number on the books of the institution. Verification of identity in any other case may be by examina. tion, for example, of a driver's license, passport, alien identification card, or other appropriate document normally acceptable as a means of identification.
Penalties.-Civil and criminal penalties are provided for failure to file a report or to supply information, and for filing a false or fraudulent report. See sections 103.47 and 103.49 of the regulations. Specific Instructions Part 1.-(1) In the address block, enter the permanent
address of the person conducting the
transaction. (2) In the social security block, enter the social
security number of the person conducting the transaction. If the person has no num.
ber, write “None" in this block. Part 11.-(1) In the name block, individuals should enter
their last name, first name and middle initial, if any, in that order. All others should enter
their complete organization name. (2) In the identifying number block, enter the
social security number or employer identi
fication number. Part III, line 6.-This part should be completed only where a check is cashed or a bank check is purchased with currency.
Part N.-Seq instruction "Identification Required." above.
Part 1.- Institutions may also enter in the namo and
address block other identifying information. Definitions
Bank.-Each agent, agency, branch or office within the United States of a foreign bank and each agency, branch or office within the United States of any person doing business in one or more of the capacities listed below. (1) a commercial bank or trust company organized under
the laws of any state or of the United States; (2) a private bank; (3) a savings and loan association or a building and loan
association organized under the laws of any state or
of the United States; (4) an insured institution as defined in section 401 of the
National Housing Act; (5) a savings bank, industrial bank or other thrift institu
tion; (6) a credit union organized under the laws of any state
or of the United States; and (7) any other organization chartered under the banking
laws of any state and subject to the supervision of the
bank supervisory authorities of a state. Currency.—The coin and currency of the United States or of any other country, which circulate in and are customarily used and accepted as money in the country in which issued. It includes United States silver certificates, United States notes and Federal Reserve notes, but does not include bank checks or other negotiable instruments not customarily ac. cepted as money.
Financial Institution. Each agency, branch or office within the United States of any person doing business in one or more of the capacities listed below:
(1) a bank;
to be registered with the Securities and Exchange Com
mission under the Securities Exchange Act of 1934; (3) a person who engages as a business in dealing in or
exchanging currency as, for example, a dealer in for. eign exchange or a person engaged primarily in the
cashing of checks; (4) a person who engages as a business in the issuing.
selling or redeeming of travelers' checks, money or. ders, or similar instruments, except one who does so as a selling agent exclusively, or as an incidental
part of another business; (5) an operator of a credit card system which issues, or
authorizes the issuance of, credit cards that may be used for the acquisition of monetary instruments,
goods, or services outside the United States. (6) a licensed transmitter of funds, or other person en
gaged in the business of transmitting funds abroad
for others. Person.-An individual, a corporation, a partnership, a trust or estate, a joint stock company, an association, a syn. dicate, joint venture, or other unincorporated organization or group, and all entities cognizable as legal personalities.
Transaction in Currency. A transaction involving the phys. ical transfer of currency from one person to another. A trans. action which is a transfer of funds by means of bank check, bank draft, wire transfer, or other written order, and which does not include the physical transfer of currency is not a transaction in currency within the meaning of this part.
DEPARTMENT OF THE TREASURY
O.M... NO. 41-ROSS
This form is to be filed with the
United States Customs Service
REPORT OF INTERNATIONAL Control Na
TRANSPORTATION OF CURRENCY 31 USC 1101:31 CFR 103.23 and 103.25
Princy Act Notification
2. IDENTIFYING NO. (See Instruction) 3. DATE OF BIRTH (M./Da./Y1.7
11. CURRENCY OR MONETARY INSTRUMENT WAS: (Complete 11A or 11B)
At: (City in U.S.)
RARITE FOR PERSON SHIPPING, MAILING OR RECEIVING CURRENCY OR MONETARY INSTRUMENTS 12. NAME (Last or family, first and middla)
13. IDENTIFYING NO. (See Instructional 14, DATE OF BIRTH (SLO Dany
22. CURRENCY OR 23. CURRENCY NAME AND ADDRESS
24. IF THE CURRENCY OR MONETARY INSTRUMENT MONETARY OR AONETARY
WAS MAILED, SHIPPED, OR TRANSPORTEO COM. INSTRUMENTS INSTRUMENTS
PLETE BLOCKS A AND 8.
A. Minthod of shipmen:uro, U.S. Hail, Public Currict, ele.)
8. Name of Transporter/Carrier Recolved
From PARERE CURREN YARD INCETARY::57RUVENT INFORMATION (SEE INSTEUOTIONS ON REVERSEN(To be completed by yonu 25. TYPC AND AMOUNT OF CURRENCY.ONETARY INSTRUMENTS
Valua Ini U.S. Dollars
126. IF OTHER THAN U.S. CUP..
RENCY IS INVOLVED, PLEASE colns ....................
COMPLETE BLOCKS A ANO ).
A. Currency Nam.
Other Instrumori! (Specily Type)
TOTAL (Aud linas A, B and C)
els BATH GENERAL. TO BE COMPLETED BY ALL TRAVELERS. SHIPPERS AN:D RECIPIENTS 27. WERE YOU ACTING AS AN AGENT. ATTORNEY OR IN CAPACITY FOR ANYONE IN THIS
CURRENCY OR MONETARY INSTRUMENT ACTIVITY? "Yes" complete A, B and C)
Un'appoingities of grjury, 'c: :1 nove vranned this raport, and to itse vast of my answiadge and giigf it is trus, correct and cap! tid.
ratirlarn:794 which HOLNOLI)
Corcoms fo:m 1790 112-29.78)
or dealer in securities in respect to currency or other monetary instruments mailed or shipped through the postal service
& Shippers or Mcilers - If the currency or other monetary Instrument does not accompany the person entering or departing the United States, Form 4790 may be filed by mall on or before the date of entry, departure, maiting, or shipping with the Commige sloner of Customs, Attention: Currancy Transportation Reports, Washington, D.C. 20229. C Travelers - Travelers carrying currency or other monetary Instruments with them shall file Form 4790 at the time of entry into the United States or the time of departure from the United States with the Customs officer in charge at any Customs port of antry or departure. 1 An additional report of a particular transporation, mailing, or shipping of currency or other monetary Instruments, is not required Na complete and ruthful report has already been files. However, no person otherwise required to file a report shall be axcused from liability for failure to do so it, in fact, a complete and truthful report has not been flind. Forms may be obtained from any United States Customs Service office. PENALTIES. -Civil and criminel penalties, including under certain circumstancos a fine ct not more than $500,000 and Imprison. ment of nct more than five yoa!s, and provided for failure to file a report, supply Informatlon, and for tiling 1 falso or fraudulont roport. In addition, the currency or monetary instrument may be subject to seizure and fortoiture. Sur sections 103.47, 103.48 and 103.43 of the regulations. Definitions
Bank. - Each agent, agency, branch or office within the United States of a foreign bank and each agency, branch or office within the United States of any person doing business in one or more of the capacities listed: (1) a commercial bank or trust company organized under the laws of any stata or of the United States; (2) a private bank:(3) a savings and loan association or a builcing and loan association organized under the laws of any state or of the United States: (4) an insu':0 insolution as aellned in section S01 of the National Housing Act: (5) a savings bank, industriai bank or other thritt institution; (6) a credit union organized under the laws of any sizia or of the Unite's 'S!2tes; and (7) any other organization chartered under the binking laws of any state and subjact to the supervision of the bank supervisory authorities of a stałc. Foroign Benk. - A bank organizad uncer foreign law, or an agency, branch or office located outside the United States of a bank. The term dcos not include an ayent, agency, branch or office within th: United States of a bank organiz:c under forurgni 12v:. Broker or Dorler in Sociritlas. - A broker or dealer in securities, regis:ored or required to be registered with the Securities and Exchango Coinmission under the Securities Exchange Act of 1934. IDENTIFYING NU!.BER. - Infviduelo should enter their social security numbər, if any. However, aliens who do not have a social security nur.cur should enter pessport or alien registration number. All others shouid enter their employer identification number,
Investment Security. - An instrurront which: (1) is issucd in bearer or registered form: (2) is ol a typa common!y dealt in upon securities or changes or markets or commonly reconnized in any area in which it is issued or dealt in as a medium for investment; (3) is estiver une of a class or scries or by its terms is divisible into a class or series of instruments: and (4) evidences a shaic, par. ticipation or other interest in property or in an enterprise or evidences an obligation of the issuer. Monctory Instruments. - Coin or currency of the United States or of any other country, travelers' checks, money orders, investment securities in bearer form or otherwise in such form that title thereto passes upon delivery, and regotiable instruirnents (except w3le. house receipts or bills of lading) in bearer form or other in such form that !itle thereto passes upun delivery. The term includes bank checks, trivalersi checks and money orders which are sinned but on which the name of the payre has been omitted, but does not in. clusin bank checks, Pravelers' checks or money orders made payable to the order of a named person which have not been endorsed or which bear restrictivo endorsements. Porson. - An individual, a corporation, a partnership, a trust or estate, a joint stock company, an association, a syndicale, joint venture, or other unincorporated organization or group, and all er.tities cognizat la as legal personalities. Special Instructions You should completo each ling which applies to you. Part II. - Line 22. Enter the exact date you shipped or received currency or the monetary instrument(s). Line 23. Check the applicable hox and siva the complete narne and address of the shipper or recipient. Part III. - Line 26. Il currency or monetary instruinents of more than one country is ir.vclvod, attach a schedule showing auch kind, country, and amount.
PRIVACY AC'T NOTIFICATION Pursuant to the requirements of Public Law 95.579. (Privacy Act of 1974), notice is herehy Rivel that the outhoney to collec: Information on Form 4790 m accordance with SUSC. 552111.) I'unlic Low 01.508, JI U.S.C.1101.5 U.S.C. JO1.Tewganization in No. 1 of 1950: Treasury De. periment No. 105, revised, us emended: JI CFR 103. The principal purpone for wlecting the information is to suure maintenance of repeuple of records where sunt reports of records huve. high degree of usefulness in crimir.l, turvatury iniestutions in proceedings. The intoxinet Cricteme ne mid-w thuce orters and employers of the customervire ind a versent unit of the Department of the Treasury who have one for ine recurdi in the performance of ther duties. The Formus may nuocirilej to ony viner deperiniche in ozency of the leger altiovernment uvun llig request of the head of auch de. partient if ney. 19 sent this refroinn Isma." I'silure to provide all in any put urinerenwel: infuriarten may sunect the currency scenetary instruments to selture and freisture, as well as suject the individual 1. concur.al la montres. Toile ingure uithe lowee!(
Yunor monilatury. The authority to collect inuenium ser H ICIN 101.25. Tae melal wioley number will me vted es nic....nenufy items, when tlies the record.
OMIR VOI. JERO 30
OFFICIAL USE ONLY
AND FINANCIAL ACCOUNTS
For the calendar year 19.
Spont if the aggregate value of the accounts did not exceed $1.000. Check all appropriate boxes. SEE INSTRUCTIONS ON BACK FOR DEFINI.
2. Social security number or ernployer 3. Name in item 1
identification number of other than refers to
0 Individual 4. Address (Street, City, State, Country, ZIP)
O Fiduciary 5. O had signature authority or other authority over one or more foreign accounts, but I had no "financial interest in such accounts (see
instruction Jl. Indicate for these accounts:
Name and social security number or taxpayer. dentification number of each owner
(Do not complete item 9 for these accounts)
Form 90-22.1. (See instruction Li. Indicate for these accounts:
(Do not compte:e item 9 for these accounts! 7. O hoch a "financial interest" in onr or more foreign accounts, but the total maximum value of these accounts (see instruction 1) did not exceed
$10,000 of any time during the year. Il you checked this box, do not complete item 3).
8. U I had wangui interest" ... 25 or more foreign accoun:s. (If you checked this box, do not complete item 9.)
9. Il you had a "financial interest in onim or more but fewer than 25 foreign accounts which are required to be reported, and the total nusximum
value cl thor.ucnunts cxceed! $10.000 during the year (sce instruction I), write the total number of those accounts here: Couplete itent: (a) throuh (1) Urinw Ini uning of the accounts and attach a separate Forin 90 22.1 for each of the others.
Item: 1,2,3.9.and:0 must curr.picted for each account. Check liere if this is an attachrornt. (al Narr in which account is inu.nthieu
(b) Name of bank or other person with whom account is nisintamod
W Number an! ciher account designation, if any
(Jl Address of office or branch where account is mjintained
le) Type of account. Ili noi certain yi English name for the type of account, give the foreign languace name and describe the nature of the account,
Altach additional sects it accessory.)
$10.000 10 $50,000
O Over $100.000
sells, holds, or trades stock or other securities for the benefit of another.
The term "other financial account means any other account maintaincd with a financiar institution or other por. son who accopts deposits, exchanges or transmits funds, or acts as a brokor or dealer for future transactions in any commodity on (or subject to the rules ot) a cominodity exchange or association.
A. Who Must Flle a Report-Each United States person who has a financial interest in or signature authority or other authority over bank, securities, or other financial accounts in a foreign country, which exceeded $1.000 in aggregate valuo at any time Cuting the calendar year, must report that relationship each calendar year by foling Form 90-22.1 with the Department of the Treasury on or betore June 30, of the succeeding year.
An officer or employee of a commer. clal bank which is subject to the supervi. sion of the Comptroller of the Currency, the Board of Governors of the Federal Reserve System, or the Federal Deposit Insurance Corporation need not report that he has signature or other authority over a foreign bank, securities or other financial account maintained by the bank unless he has a personal linancial Interest in the accoun:.
In addition, an officer or employee of a domestic corporation whose securities are listed upon national securities ex. changes or which has assets exceeding $1 million and 500 or more shareholders of record need not lile such a report con. carring his signature authority over a foreign financial account of the corpora. tion, it he has no personal financial interest in the account and has been adviscd in writing by the chief financial officer of the corporation that the corporation has filed a current report which Includes that account.
B. United States Parson-The term "United States person" means (1) a citizen or resident of the United States, 2) a domestic partnership. (3) a domestic corporation, or (4) a domestic estate or trust.
C. When and where to File-This Prich shall be filed on or before June 30 Each calendar year with the Department of the Treasury, Post Office Box 28309, Central Station, Washington, D.C., 20005.
D. Account in a Foreign country-A foreign country" includes all geographical areas located outside the Uniieu States, Guam, Puerto Rico, and the Virgin Islands.
Report any account maintained with a bank (except a militury banking facility as delined in instruction E) or broker or Ccalor in securities that is locate in a forsigo country, even if it is a part of a United States bank or other institution. Do not report any account maintained with a branch, agency, or cthor office of a foreign lank of o:ner institution that is locaies in the United States, Guam, Puerto Rico, and the Virgin Islands.
E. N.llitary Banking Facility-Do not consider as an account in a foreign country, an account in an institution known as a "United States military bank. Ing facility" (or "Unitud 3!atos military tinar:co facility") operated by a United States financial institution designated by the United States Government to serve U.S. Government installations atron, ruven if the United Statos military banking facility is located in a foreign country.
F. Dank, Financial Account - The torm "0.10k acc.):11;" from ins a cari.;. demand, chirck.ng Groosil, !0.1n or iny other count 01.31. 1.14.. with a linn. civitations... Pron Inc.;
': CS:1.1. 0.01 01:11
TT 1.::: ui... ICCO'nt" mo...3 an ...11:05.6.7...!! it a tini... insului).1 34 3:11.1 Person who buys,
G. Financial Interest - A financial interest in a bank, securities, or other financial account in a foreign country means an interest described in either of the following two paragraphs:
(1) A United States person has a finan. cial interest in each account for which such person is the owner of records or has legal title, whether the account is maintained for his or her own benefit or for the benefit of others including nonUnited States persons. It an account is maintained in the name of two persons jointly, or if several persons each own a partial interest in an account, each of those United States persons has a linancial interest in that account.
(2) A United States person has a finan. cial interest in each bank, securities, or other financial account in a foreign country for which the owner of record or holder of legal title is: (a) a person acting as an agent, nominee, attorney. or in some other capacity on behalf of the U.S. person; (b) a corporaiion in which the United States person owns directly or indirectly more than 50 percent of the total value of shares of stock; (c) a partnership in which inc United States per son owns an interest in more than 50 percont of the profils (distributive share of income); or (d) a trust in which the United States person either has a present beneticial intercst in more than 50 per. cont of the assets or from which such person receives more than 30 percent of the current income.
For purposes of items 7, 9, and Instruction A, if you had a financial in. terest in more than one account, each account is to be valued separately in ac. cordance with the foregoing two paragraphs.
If you had a financial interest in one or more but lewer than 25 accounts, and you aro unable lo determine whether the maximum value of tivese accounts ex. ceeded $10,000 at any time during the year, check item 9 (do not chock itern 7) and complete Item 9 for each of these accounts.
J. United States Persons with Authority Over but No Interest in an Ac. count-Exccpt as provided in Instruc. tion A ard the following paragraph, you must state the name, address, and iden. tifying number of each owner of an ac. count over which you hac authority, but if you check item 5 for more than one ac. count of the same owner, you need identity the owner only once.
If you check item 5 for one or inore ac. counts in which no United States person had a financial interest, you may stale on the first line of ihis item, in licu of supplying in!ormation about the owner, "NO U.S. person had any financial interest in the foreign accounts." This statement must be based upon the actual beliel of the person tiling this form after he or she has taken reasonable measures to endure its correctness.
If you check item 5 for accounts owned by a domestic corporation and its domestic and/or foreign subsidiaries, you may treat them as one owner and write in the space providec, the name of the parent corporation, foliowed by "and related entities," and the identifying number and address of the parent cor. poration:
K. CC:15olidated Reporting
A corporation which ovins directly or Indirectly more thar: 50 cercont interest in ore or more biher entitics will te per. mitted to file a consolidated report 0.1 Form 90-22.1, on teholl of itscit anul such othe: entities provided that a listing of them is made part of iho cun. solidated :eport. Such reports should be signed by in auiherices ci!icial of the parent corporation.
If the group of entities covered by a consolidated reports a financial in. terest in 25 or more icreign firancial ac. counts, the reporting corporation necd only note that iact on the form; it will,
waver, be required to provide colaed Information concerniny each account when so requested by the Secretary or his delegato.
L. Avoiding Duplicats Reporting-11 you haj financial ingrost (as defined in instruction G23). c) or (d) in one or more accoun!s which are owncd by a domestic corporation, partnrship or trust which is reauired to filc Form 90-22.1 with respect to theso accounts in lieu of coinpieting itein 9 for each ac. count you may check item 6 and provido the routired intorinalion.
M. Providing Additional Informa. tion- Any person who doci not com. plete item 9, shl whon raguostou by ito Dapartinent : the Treasury provid: tho information callcd for in or 9
N. Signalu:0 (Item 101 - 76. report must be signrd by the person 31noy in itorn 1. li the res!! is bem !
:) un lehall of a partnership. Counration, a fiduciary. 1: murit La Signwil by in guchi
... .O. f'61.11.'.-Frontrol penittre. for ljuures olv 31., 1:1. Surprol:20). tion, and to bring a telur tasqulur! reports 31 U.SC. 102, 31SC, an 18 USG 1001..
H. Signature or Olhar Autho:ily Over an Account
Signature Authority -A person has Signature authority over an account it Such person cari contro ine disposition of money or other property in it by delivery of a docuinent containing his or hor signature (or his or her signature and that of one or more other persons) to i ho bank or other person with whom the ac. count is maintained.
Other authority exists in a person who can exercise corpurable power over an account by direct communication to the bank or other person with whoin the account is niaintained, either orally or by some other moins.
1. Account Valuation-For items 7, 9, and Instruction A, tho it.axirnum vaius of an account is the iargest amount of cur. rency ar.d non-monctary assets that ap. pear on any quarterly more frequ. account staternent issued for iho applicable year. If periodic account statements are not so issued, the max. imum account ascct value is the largest amount of currcrcy and non monetary asscis in the account at any timo curine) the year. Convert torn currency by us. ing tho ollicial exc1.2:10; rate at the end of the year. In valuing 1.01rency olar.gur. try that use: mitoilipo xhan, rains. use the rate which would fly of t1 CH. fenicy in thn Account cre convertitit) United States ullars alte close of 1.! calendar year.
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