FINCEN Form 104 Currency Transaction Report

(Formerly Form 4789)

Previous editions will not be accepted after August 31, 2004.
(Eff. December 2003)
Please type or print.
Department of the Treasury
FinCEN (Complete all parts that apply--See Instructions) OMB No. 1506-0004
1 Check all box(es) that apply: a Amends prior report b Multiple persons c Multiple transactions
Part I Person(s) Involved in Transaction(s)
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
2 Individual’s last name or entity’s name 3 First name 4 Middle initial
Bull Debbie
5 Doing business as (DBA) 6 SSN or EIN
3 5 7 6 2 9 2 5 6
7 Address (number, street, and apt. or suite no.) 8 Date of birth
____/____/_______
12/30/1962
2704 E Washington St MM DD YYYY
9 City 10 State 11 ZIP code 12 Country code 13 Occupation, profession, or business
(if not U.S.)
Bloomington I L 61704 Procurement Specialist/SF
14 If an individual, describe method used to verify identity: a ✔ Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: IL f Number:

B400-1726-2971

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)
a Armored Car Service b Mail Deposit or Shipment c Night Deposit or Automated Teller Machine d Multiple Transactions e Conducted On Own Behalf

15 Individual’s last name 16 First name 17 Middle initial

18 Address (number, street, and apt. or suite no.) 19 SSN

20 City 21 State 22 ZIP code 23 Country code 24 Date of birth

(If not U.S.) ____/____/_______
MM DD YYYY
25 If an individual, describe method used to verify identity: a Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: f Number:

Part II Amount and Type of Transaction(s). Check all boxes that apply.
28 Date of transaction
26 Total cash in $ 0 .00 27 Total cash out $ 12000 .00 ____/____/_______
08/20/2010
MM DD YYYY
26a Foreign cash in 0 .00 27a Foreign cash out 0 .00
(see instructions, page 4) (see instructions, page 4)

29 Foreign Country 30 Wire Transfer(s) 31 Negotiable Instrument(s) Purchased

32 Negotiable Instrument(s) Cashed 33 Currency Exchange(s) 34 Deposit(s)/Withdrawal(s)

35 ✔ Account Number(s) Affected (if any): 36 Other (specify)

42295871

Part III Financial Institution Where Transaction(s) Takes Place

37 Name of financial institution Enter Regulator or BSA
Examiner code number
Busey Bank (see instructions)
38 Address (number, street, and apt. or suite no.) 39 EIN or SSN
2402 E Washington St
40 City 41 State 42 ZIP code 43 Routing (MICR) number
Bloomington I L 61704
44 Title of approving official 45 Signature of approving official 46 Date of signature
Teller Manager ____/____/_______
08/20/2010
Sign MM DD YYYY
Here 47 Type or print preparer’s name 48 Type or print name of person to contact 49 Telephone number

Teela Lane Kali Fulcher (3 0 9 ) 6 6 3 6 4 4 4

For Paperwork Reduction Act Notice, see page 4. Cat. No. 37683N FinCEN Form 104 (Formerly Form 4789) (Rev. 08-03)
FinCEN Form 104 (formerly Form 4789) (Eff. 12-03) Page 2

Multiple Persons
Complete applicable parts below if box 1b on page 1 is checked

Part I Person(s) Involved in Transaction(s)

Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
2 Individual’s last name or entity’s name 3 First name 4 Middle initial
Bull Ronald
5 Doing business as (DBA) 6 SSN or EIN
3 3 9 6 0 5 9 8 3
7 Address (number, street, and apt. or suite no.) 8 Date of birth
____/____/_______
2704 E Washington St MM DD YYYY
9 City 10 State 11 ZIP code 12 Country code 13 Occupation, profession, or business
(if not U.S.)
Bloomington I L 61704
14 If an individual, describe method used to verify identity: a ✔ Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: f Number:

Section B--Individual(s) Conducting Transaction(s) (if other than above).

15 Individual’s last name 16 First name 17 Middle initial

18 Address (number, street, and apt. or suite no.) 19 SSN

20 City 21 State 22 ZIP code 23 Country code 24 Date of birth

(if not U.S.) ____/____/_______
MM DD YYYY
25 If an individual, describe method used to verify identity: a Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: f Number:

Part I Person(s) Involved in Transaction(s)

Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted
2 Individual’s last name or entity’s name 3 First name 4 Middle initial

5 Doing business as (DBA) 6 SSN or EIN

7 Address (number, street, and apt. or suite no.) 8 Date of birth

____/____/_______
MM DD YYYY
9 City 10 State 11 ZIP code 12 Country code 13 Occupation, profession, or business
(if not U.S.)

14 If an individual, describe method used to verify identity: a Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: f Number:

Section B--Individual(s) Conducting Transaction(s) (if other than above).

15 Individual’s last name 16 First name 17 Middle initial

18 Address (number, street, and apt. or suite no.) 19 SSN

20 City 21 State 22 ZIP code 23 Country code 24 Date of birth

(if not U.S.) ____/____/_______
MM DD YYYY
25 If an individual, describe method used to verify identity: a Driver’s license/State I.D. b Passport c Alien registration

d Other e Issued by: f Number:

FinCEN Form 104 (Eff. 12-03) Page 3

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