FinCEN Form

March 2011

105

DEPARTMENT OF THE TREASURY FINANCIAL CRIMES ENFORCEMENT NETWORK

OMB NO. 1506-0014

Department of the Treasury FinCEN

Please type or print.

REPORT OF INTERNATIONAL TRANSPORTATION OF CURRENCY OR MONETARY INSTRUMENTS

2. IDENTIFICATION NO. (See instructions)

To be filed with the Bureau of Customs and Border Protection For Paperwork Reduction Act Notice and Privacy Act Notice, see back of form.
31 U.S.C. 5316; 31 CFR 1010.340 and 1010.306

PAR T I

FOR A PERSON DEPARTING OR ENTERING THE UNITED STATES, OR A PERSON SHIPPING, MAILING, OR RECEIVING CURRENCY OR MONETARY INSTRUMENTS. (IF ACTING FOR ANYONE ELSE, ALSO COMPLETE PART II BELOW.)
3. DATE OF BIRTH (Mo./Day/Yr.)

1. NAME (Last or family, first, and middle)

4. PERMANENT ADDRESS IN UNITED STATES OR ABROAD

5. YOUR COUNTRY OR COUNTRIES OF CITIZENSHIP

7. PASSPORT NO. & COUNTR Y

6. ADDRESS WHILE IN THE UNITED STATES

8. U.S. VISA DATE (Mo./Day/Yr.)

9. PLACE UNITED STATES VISA WAS ISSUED

10. IMMIGRATION ALIEN NO.

11. IF CURRENCY OR MONETARY INSTRUMENT IS ACCOMPANIED BY A PERSON, COMPLETE 11a OR 11b, not both A. EXPORTED FROM THE UNITED STATES
Departed From: (U.S. Port/City in U.S.)

COMPLETE A OR B NOT BOTH

B. IMPORTED INTO THE UNITED STATES

Arrived At: (City in U.S.)

Arrived At: (Foreign City/Country)

Departed From: (Foreign City/Country)

12. IF CURRENCY OR MONETARY INSTRUMENT WAS MAILED OR OTHERWISE SHIPPED, COMPLETE 12a THROUGH 12f
12a. DATE SHIPPED (Mo./Day/Yr.) 12b. DATE RECEIVED (Mo./Day/Yr.) 12c. METHOD OF SHIPMENT (e.g. u.s. Mail, Public Carrier, etc.) 12d. NAME OF CARRIER

12e. SHIPPED TO (Name and Address)

12f. RECEIVED FROM (Name and Address)

P A R T II INFORMATION ABOUT PERSON(S) OR BUSINESS ON WHOSE BEHALF IMPORTATION OR EXPORTATION WAS CONDUCTED
13. NAME (Last or family, first, and middle or Business Name) 14. PERMANENT ADDRESS IN UNITED STATES OR ABROAD 15. TYPE OF BUSINESS ACTIVITY, OCCUPATION, OR PROFESSION 15a. IS THE BUSINESS A BANK? Yes No

P A R T III CURRENCY AND MONETARY INSTRUMENT INFORMATION (SEE INSTRUCTIONS ON REVERSE)(To be completed by everyone)
16. TYPE AND AMOUNT OF CURRENCY/MONETARY INSTRUMENTS
Currency and Coins Other Monetary Instruments (Specify type, issuing entity and date, and serial or other identifying number.)

$ $ $

17. IF OTHER THAN U.S. CURRENCY IS INVOLVED, PLEASE COMPLETE BLOCKS A AND B. A. Currency Name

B. Country

(TOTAL)

P A R T IV SIGNATURE OF PERSON COMPLETING THIS REPORT

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief it is true, correct and complete.
18. NAME AND TITLE (Print) 19. SIGNATURE 20. DATE OF REPORT (Mo./Day/Yr.)

CUSTOMS AND BORDER PROTECTION USE ONLY

THIS SHIPMENT IS DATE INBOUND OUTBOUND PORT CODE CBP QUERY? Yes LICENSE PLATE STATE/COUNTRY NUMBER No COUNT VERIFIED Yes No VOLUNTARY REPORT Yes No

AIRLINE/FLIGHT/VESSEL

INSPECTOR (Name and Badge Number)

FinCEN FORM 105

GENERAL INSTRUCTIONS
This report is required by 31 U.S.C. 5316 and Treasury Department regulations (31 CFR Chapter X).

WHO MUST FILE:

(1) Each person who physically transports, mails, or ships, or causes to be physically transported, mailed, or shipped currency or other monetary instruments in an aggregate amount exceeding $10,000 at one time from the United States to any place outside the United States or into the United States from any place outside the United States, and

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 institution; (6) a credit union organized under the laws of any State or of the United States; (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 other than a money service business; (8) a bank organized under foreign law; and (9) any national banking association or corporation acting under the provisions of section 25A of the Federal Reserve Act (12 U.S.C. Sections 611-632).

Foreign BankA bank organized under foreign law, or an agency, branch or office located outside the United States of a bank. The term does not include an agent, (2) Each person who receives in the United States currency or other monetary agency, branch or office within the United States of a bank organized under foreign instruments In an aggregate amount exceeding $10,000 at one time which have been law. transported, mailed, or shipped to the person from any place outside the United States. Broker or Dealer in Securities A broker or dealer in securities, registered or A TRANSFER OF FUNDS THROUGH NORMAL BANKING PROCEDURES, WHICH required to be registered with the Securities and Exchange Commission under the DOES NOT INVOL VE THE PHYSICAL TRANSPORTATION OF CURRENCY O R Securities Exchange Act of 1934. MONETARY INSTRUMENTS, IS NOT REQUIRED TO BE REPORTED. Currency: The coin and paper money of the United States or any other country that Exceptions: Reports are not required to be filed by: is (1) designated as legal tender and that (2) circulates and (3) is customarily accepted as a medium of exchange in the country of issuance. (1) a Federal Reserve bank, , . (2) a bank, a foreign bank, or a broker or dealer in securities in respect to currency Identification NumberIndividuals must enter their social security numberif any However, or other monetary instruments mailed or shipped through the postal service or by common aliens who do not have a social security number should enter passport or alien registration number. All others should enter their employer identification number . carrier, (3) a commercial bank or trust company organized under the laws of any State or of the United States with respect to overland shipments of currency or monetary instruments shipped to or received from an established customer maintaining a deposit relationship with the bank, in amounts which the bank may reasonably conclude do not exceed amounts commensurate with the customary conduct of the business, industryor profession , of the customer concerned, (4) a person who is not a citizen or resident of the United States in respect to currency or other monetary instruments mailed or shipped from abroad to a bank or broker or dealer in securities through the postal service or by common carrier , (5) a common carrier of passengers in respect to currency or other monetary instruments in the possession of its passengers, (6) a common carrier of goods in respect to shipments of currency or monetary instruments not declared to be such by the shipper , Monetary Instruments (1) Coin or currency of the United States or of any other country (2) , travelers checks in any form, (3) negotiable instruments (including checks, promissory notes, and money orders) in bearer form, endorsed without restriction, made out to a fictitious payee, or otherwise in such form that title thereto passes upon delivery (4) incomplete instruments , (including checks, promissory notes, and money orders) that are signed but on which the name of the payee has been omitted, and (5) securities or stock in bearer form or otherwise in such form that title thereto p asses upon delivery Monetary instruments do not include (i) checks or . money orders made payable to the order of a named person which have not been endorsed or which bear restrictive endorsement , (ii) warehouse receipt , or (iii) bills of lading. s s PersonAn individual, a corporation, partnership, a trust or estate, a joint stock comp any, an association, a syndicate, joint venture or other unincorporated organization or group, an Indian Tribe (as that term is defined in the Indian Gaming Regulatory Act), and all entities cognizable as legal personalities.

SPECIAL INSTRUCTIONS:

(7) a travelers check issuer or its agent in respect to the transportation of travelers You should complete each line that applies to you. PART I. Complete 11A or 11B, checks prior to their delivery to selling agents for eventual sale to the public, not both. Block 12A and 12B; enter the exact date you shipped or received currency or monetary instrument(s). PART II. -Block 13; provide the complete name (8) a person with a restrictively endorsed traveler check that is in the collection of the shipper or recipient on whose behalf the exportation or importation was s and reconciliation process af er the travelers check has been negotiated, nor by t conducted. PART III. Specify type of instrument, issuing entity , and date, serial (9) a person engaged as a business in the transportation of currency, monetary or other identifying number, and payee (if any). Block 17, if currency or monetary instruments and other commercial papers with respect to the transportation of currency instruments of more than one country is involved, attach a list showing each type, or other monetary instruments overland between established offices of banks or brokers country or origin and amount. or dealers in securities and foreign persons.

WHEN AND WHERE TO FILE:

A. RecipientsEach person who receives currency or other monetary instruments in the United States shall file FinCEN Form 105, within 15 days after receipt of the currency or monetary instruments, with the Customs officer in charge at any port of entry or departure or by mail with the Commissioner of Customs, Attention: Currency Transportation Reports, Washington DC 20229. B. Shippers or Mailers lf the currency or other monetary instrument does not accompany the person entering or departing the United States, FinCEN Form 105 may be filed by mail on or before the date of entry , departure, mailing, or shipping with the Commissioner of Customs, Attention: Currency Transportation Reports, Washington DC 20229. C. Travelers Travelers carrying currency or other monetary instruments with them shall file FinCEN Form 105 at the time of entry into the United States or at the time of departure from the United States with the Customs officer in charge at any Customs port of entry or departure. An additional report of a particular transportation, mailing, or shipping of currency or the monetary instruments is not required if a complete and truthful report has already been filed. However, no person otherwise required to file a report shall be excused from liability for failure to do so if, in fact, a complete and truthful report has not been filed. Forms may be obt ined from any Bureau of Customs and Border Protection office. a PENALTIES: Civil and criminal penalties, including under certain circumstances a fine of not more than $500,000 and Imprisonment of not more than ten years, are provided for failure to file a report, filing a report containing a material omission or misstatement, or filing a false or fraudulent report. In addition, the currency or monetary instrument may be subject to seizure and forfeiture. See 31 U.S.C.5321 and 31 CFR 1010.820; 31 U.S.C. 5322 and 31 CFR 1010.840; 31 U.S.C. 5317 and 31 CFR 1010.830, and U.S.C. 5332.

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE:

Pursuant to the requirements of Public law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on Form 105 in accordance with 5 U.S.C. 552a(e)(3) is Public law 91-508; 31 U.S.C. 5316; 5 U.S.C. 301; Reorganization Plan No.1 of 1950; Treasury Department Order No. 165, revised, as amended; 31 CFR Chapter X; and 44 U.S.C. 3501. The principal purpose for collecting the information is to assure maintenance of reports or records where such reports or records have a high degree of usefulness in criminal, tax, or regulatory investigations or proceedings. The information collected may be provided to those officers and employees of the Bureau of Customs and Border Protection and any other constituent unit of the Department of the Treasury who have a need for the records in the performance of their duties. The records may be referred to any other department or agency of the Federal Government upon the request of the head of such dep artment or agency. The information collected may also be provided to appropriate state, local, and foreign criminal law enforcement and regulatory personnel in the performance of their official duties. Disclosure of this information is mandatory pursuant to 31 U.S.C. 5316 and 31 CFR Chapter X. Failure to provide all or any part of the requested information may subject the currency or monetary instruments to seizure and forfeiture, as well as subject the individual to civil and criminal liabilities. Disclosure of the social security number is mandatory . The authority to collect this number is 31 U.S.C. 5316(b) and 31 CFR 1010.306(d). The social security number will be used as a means to identify the individual who files the record. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The collection of this information is mandatory pursuant to 31 U.S.C. 5316, of Title II of the Bank Secrecy Act, which is administered by Treasurys Financial Crimes Enforcement Network (FINCEN).

Statement required by 5 CFR 1320.8(b)(3)(iii): The estimated average burden associated with this collection of information is 1 minutes per respondent or record keeper depending on individual circumst 1 ances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden BankEach agent, agency, branch or office within the United States of any person artment of the T reasury, Financial Crimes Enforcement Network, P Box 39 .O. doing business in one or more of the capacities listed: (1) a commercial bank or trust should be directed to the Dep T company organized under the laws of any State or of the United States; (2) a private Vienna, Virginia 22183. DO NOT send completed forms to this officeSee When and Whereo bank; (3) a savings association, savings and loan association, and building and loan File above.

DEFINITIONS:

FinCEN FORM 105