5 Appendix I Examples of the Completion of the FinCEN Currency ...

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Currency Transaction Report
Part I Person Involved in Transaction 1 of 3
+ -
*2 a
Person conducting
transaction on own behalf
3 Multiple transactions
b
Person conducting
transaction for another
c
Person on whose behalf
transaction was conducted
d
Courier Service (private)
Check
If entity
*4 Individual's last name
or entity's legal name
Unknown
Davis
*5 First name Unknown William
6 Middle name B
Suffix
7 Gender
8 Alternate Name
9 Occupation or type of business Real Estate Broker
9a NAICS Code 5313
*10 Address
Unknown
100 Dorsey Hall Drive
*11 City
Unknown
Columbia
*12 State
Unknown MD
*13 ZIP/Postal Code Unknown 21044
*14 Country
Unknown
US
*15 TIN
Unknown 258741000
16 TIN type SSN-ITIN
*17 Date of birth
Unknown
09/20/1965
18 Contact phone number 4435551212 Ext.
19 E-mail address william.davis@aol.com
*20 Form of identification used to verify identity Unknown
Driver's license/State ID Passport Alien Registration Other
Number 258963215741 Country
US
Issuing State MD
21 Cash in amount for individual or entity listed in Item 4 $ 23,000
Account number 698523645
+
-
22 Cash out amount for individual or entity listed in Item 4 $
Account number
+ -
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