om 8300

(Rev. January 1990)

Department of the Treasury
Internal Revenue Service

Report of Cash Payments Over $10,000
Received in a Trade or Business

Failure to file this form or filing a false form may result in imprisonment.

OMB No. 1545-0892
Expires: 10-31-92

> See instructions on back.

Please type or print.

1 Check appropriate boxes if:

‘a_LJ amends prior report;

b_L] suspicious transaction.

Identity of Individual From Whom the Cash Was Received

2__ If more than one individual is involved, see instructions and check here .

> 0

3 Last name

4 First name

5 Middle initial 6 Social security number

7 Address (number and street)

8 Occupation, profession, or business

9 City

10 State {11 ZIP code {12

Country (if not U.S.) |13 Date of birth (see instructions)

poi ot

14 Method used to verify identity:
b Issued by

a Describe identification >

c Number

Person (See Definitions) on Whose Behalf This Transaction Was Conducted

15 ___ If this transaction was conducted on behalf of more than one person, see instructions and check here_.

- OU

16 This personis an: [] individual or [] organization [17 If funded by another party, see instructions and check here .

Oo

18 — Individual's last name or Organization's name|19 First name

20 Middle initial |21 Social security number

22 Alien identification:
b Issued by

a Describe identification

c

Employer identification number

23 Address (number and street)

24 Occupation, profession, or business

25 City

26 State |27 ZIP code |28

Country (if not U.S.) |29 Date of birth (see instructions)

n i

| Part 111 | Description of Transaction and Method of Payment

30a C1 personal property purchased
b CO real property purchased
c CL personal services provided

d CO business services provided

g OC exchange of cash

e CJ intangible property purchased h C1 escrow or trust funds

t CO debt obligations paid

i_U other (specify) >

31. Specific description of property or service purchased. Give serial or registration number of car, boat, airplane, etc., address of real estate, etc.

32_ Total price $

.00]33 Amount of cash received $

.00[ 34 Amount in $100 bills or larger $ .00

35 If part of an installment sale, give information below and check box on
b Amount of each payment $ .00 Poy Ge 4

a Number of payments
¢ Frequency: _] monthly

L other (describe)

> (J |36 Date of transaction

d Balloon payment (amount) $ .00

37 (J Paid with U.S. currency

[Paid with foreign currency (country)

Amount (U.S. dollar equivalent) $ 00

Business Reporting This Transaction

38 Name of reporting business

39 Employer identification number

40 Street address where transaction occurred

Social security number

41 City

42 State |43 ZIP code |44

Nature of your business

45 Under penalties of perjury, | declare that to the best of my knowledge the information | have furnished above is true, correct, and

complete.

Sign
Here

(Authorized signature—See Instructions)

(Title)

(Date signed) (Telephone number)

Paperwork Reduction Act Notice.—The requested information is useful in criminal, tax, and regulatory investigations, for instance by
directing the Federal Government's attention to unusual or questionable transactions. Trades or businesses are required to provide the

information under 26 U.S.C. 60501.

The time needed to complete this form will vary depending on individual circumstances. The estimated average time is 18 minutes. If
you have comments concerning the accuracy of this time estimate or suggestions for making this form more simple, you can write to the
Internal Revenue Service, Washington, DC 20224, Attention: IRS Reports Clearance Officer T:FP; or the Office of Management and
Budget, Paperwork Reduction Project (1545-0892), Washington, DC 20503.

Form 8300 (Rev. 1-90)


Form 8300 (Rev. 1-90)

Page 2

General Instructions

Who Must File.—Each person engaged in a
trade or business who, in the course of such trade
or business, receives more than $10,000 in cash
in one transaction or two or more related
transactions must file Form 8300. Any
transactions conducted between a payer (or its
agent) and the recipient in a 24-hour period are
related transactions and must be aggregated and
reported as a single transaction if the total
amount exceeds $10,000. Also, a transaction is
related even though it occurs during a period of
more than 24 hours if the recipient knows, or has
reason to know, that each transaction 1s one of a
series of connected transactions. In addition, this
form may voluntarily be filed for any suspicious
transaction, even if it does not exceed $10,000.
Multiple Payments.—How and when you must
report receipt of cash deposits, cash installment
payments, or other similar payments or
prepayments depend upon the dollar amounts of
the initial and subsequent payments.

If the initial payment exceeds $10,000, it must
be reported within 15 days. If the initial payment
does not exceed $10,000, the recipient must add
together the initial payment and subsequent
payments made within one year until the total
exceeds $10,000, at which time the report must
be filed within 15 days. If subsequent payments,
singly or in the aggregate, received within any
one-year period exceed $10,000, they must be
reported separately within 15 days of the date
they exceed $10,000 if they have not been
previously reported. (If two or more separately
reportable payments are received less than 15
days apart, they may be filed on a single report. In
this case, the report is due within 15 days of
receipt of the first payment.) If subsequent
payments, singly or in the aggregate, received
within one year do not exceed $10,000, they
need not be reported,

Exceptions.—Section 1.6050I-1 of the Treasury
Regulations provides for exceptions to the
reporting requirements, including:

(2) Financial institutions required to file Form
4789, Currency Transaction Report, are
exempted from filing Form 8300 for the same
transaction.

(2) Casinos required to file (or excepted from
filing) Form 8362 are exempted from filing Form
8300 for the same transaction. However,
nongaming businesses (such as shops,
restaurants, and hotels) at the casinos must
report on Form 8300 receipt of cash in excess of
$10,000.

(3) Cash received by a person other than in the
person’s trade or business is not reportable.

(4) Cash transactions that occur entirely
outside the United States are generally exempt
from the reporting requirements, The United
States includes the 50 states and the District of
Columbia. However, if any part of the transaction
occurs in Puerto Rico, or a possession or territory
of the United States, and the recipient is subject
to the general jurisdiction of the IRS under the
Internal Revenue Code, the transaction must be
reported by the recipient.

(5) An agent who: (a) receives cash from a
principal, (b) uses all of the cash within 15 days
ina cash transaction that is reportable on Form
8300 or 4789, and (c) discloses all of the
information necessary to complete Part Il of Form
8300 to the recipient of the cash in the second
transaction does not have to file Form 8300 for
the initial receipt of the cash.

When and Where To File, —File this form by the
15th day after the date of the transaction with
the Internal Revenue Service, Detroit Computing
Center, P.O. Box 32621, Detroit, MI 48232, or
with your local IRS office. Keep a copy of each
Form 8300 for 5 years from the date you file it.
Penalties. —Civil and criminal penalties including
up to 5 years imprisonment are provided for
failure (or causing the failure) to file a report, for
filing (or causing the filing) of a false or fraudulent
report, and for structuring a transaction.

Statement To Be Provided.—A written
statement must be provided to each person
named in this form on or before January 31 of the
year following the calendar year in which this
report is made. The statement must show the
name and address of the business, the total
amount of reportable cash received, and that the
information was furnished to the IRS. Keep a
copy for your records.

Specific Instructions

Item 1.—If you are reporting a suspicious
transaction (see Definitions), check Box 1b. For a
suspicious transaction, you are also encouraged
to telephone the local Internal Revenue Service
Criminal Investigation Division. If you do not
know the number, please call toll-free 1-800-
BSA-CTRS.

Part I.—This part must always be completed.
Item 2.—Check the box if two or more
individuals conducted the transaction you are
reporting. Enter identifying information in Part |
for one of the individuals. Provide information on
the other individual(s) on additional sheets of
paper and attach them to this report.

Item 6.—Enter the social security number of the
individual named in Part |. If the individual has no
number, enter “None.”

Item 8.—In identifying the occupation,
profession, or business of the individual named in
Part |, use fully descriptive terms such as
plumber, attorney, etc., and not nondescriptive
terms such as merchant, businessman, self-
employed, etc.

Item 13.—Enter six numerals for the date of
birth of the individual named in Part |. For
example, if the individual's birth date was July 6,
1960, enter 07 06 60.

Item 14.—You must verify the name and
address of the individual identified in Part |.
Verification must be made by examination of a
document normally acceptable as a means of
identification when cashing checks (for example,
a driver's license, passport, or other official
document). In Item 14a, enter the type of
document used to verify the identification. In
Item 14b, identify the issuer of that document. In
Item 14c, enter the document's number. For
example, if the individual has a Utah driver's
license, enter “driver's license” in Item 14a,
“Utah” in Item 14b, and its number in Item 14c.
Part Il.—If the individual in Part | is conducting
the transaction for himself or herself only, do not
complete Part Ii. In all other cases, complete
Part Il

Item 15.—If the transaction is being conducted
on behaif of more than one person (e.g., 2
persons are jointly purchasing a vehicle), check
the box and complete Part II on any one of the
persons. Provide the same information requested
in Part Il on the other person(s) on additional
sheets of paper and attach them to this report.
Item 16.—If the person identified in Part Il is an
individual, check the “individual” box. For any
person other than an individual, check the
“organization” box. Check both boxes if the
transaction is on behalf of both an individual and
an organization.

Item 17.—Check the box if any of the cash
received is from a party or parties not identified
in Part | or Il. Provide the same information
requested in Part II on that party or parties on
additional sheets of paper and attach them to
this report.

Items 18, 19, and 20.—If the person on whose
behalf the transaction was conducted was an
individual, put his or her last name in Item 18,
first name in Item 19, and middle initial in Item
20. If the person is an organization, put its name
in tem 18 and leave Items 19 and 20 blank.
Item 21.—If the person is an individual, enter
his or her social security number; if not an
individual, enter its employer identification
number. If the person does not have a social
security or employer identification number,
enter “None.”

Item 22.—If the person is an alien without a
social security number, complete this item. Enter
a general description of the type of official
document issued to that person in Item 22a (e.g.,
“passport”), the country that issued the
document in Item 22b, and the document's
number in Item 22c.

Item 29.—Refer to Item 13.

Part Ill. —This part must always be completed.
Item 30.—Check the appropriate box(es) that
describe the transaction. If the transaction is not
specified in Boxes a —h, check Box i and briefly
describe it (e.g., car lease).

Items 32, 33, and 34.—Provide the total price
of the goods purchased, services provided,
amount of cash exchanged, etc. (e.g., the total
cost of a vehicle purchased, cost of catering
service, exchange of currency) in Item 32, Enter
the total amount of cash received reportable on
this return (see Multiple Payments for reporting
requirements) in Item 33 and the amount of
$100 (and larger) bills in Item 34. Show only
nearest dollar amounts. Round 50 cents or more
‘to the next whole dollar.

Item 35.—If the transaction is part of an
installment sale, check the box. In Item 35a,
enter the number of payments agreed upon; in
Item 35b, enter the amount of each installment
payment; in Item 35c, check the “monthly” box if
the payments are to be made monthly, or the
“other” box if the payments are made at any
other intervals and describe the intervals (e.g.
weekly, semr-annually, etc.). If the installments
are for different amounts, attach a schedule.
Item 36.—If the aggregate amount of cash
received in two or more installment payments
exceeds $10,000, enter the payment date that
causes the aggregate amount to exceed

$10,000. Also, see Multiple Payments.

Item 37.—Check the appropriate box(es). If
foreign currency is used, provide the country of
issuance and the amount (in U.S, dollar
equivalent) in the spaces provided. If currency of
more than one foreign country is used, enter the
information required by Item 37 on an additional
sheet of paper and attach it to this report.

Part IV.—This part must always be completed.
Item 39.—Enter the employer identification
number (EIN) of the reporting business. Enter the
‘owner's social security number only if the
business has no EIN.

Item 44.—Describe the nature of the business
filing the report. Use descriptive terms (auto
dealer, jewelry dealer) rather than nondescriptive
terms (business, store).

Item 45.—This report must be signed by an
authorized individual. Also type or print the name
of the signer below the signature.

Definitions

Person.—An individual, corporation,
partnership, trust or estate, joint stock company,
association, syndicate, joint venture, or other
unincorporated organization or group, and all
entities treated as legal personalities, including
organizations that are exempt from tax.
Cash.—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 notes and Federal Reserve notes, but does
not include bank checks or drafts, travelers checks,
wire transfers, or other negotiable or monetary
instruments not customarily accepted as money.
Suspicious Transaction.—A transaction in
which it appears that a person is attempting to.
cause this report not to be filed or a false or
incomplete report to be filed; or where there is an
indication of possible illegal activity.
Transaction.—It includes (but is not limited to)
the purchase of goods, services, personal or real
property, and intangible property by a customer;
a debt obligation paid for with cash; the receipt
and conversion of cash to a negotiable

instrument (e.g., a receipt of cash from a person
in exchange for a check); and the receipt of cash
to be held in escrow or trust.