rom 8300

(Rev. January 1986)

Department of the Treasury
internal Revenue Service

Recel

Report of Cash Payments Over $10,000

ed in a Trade or Business
» Please type or print.

OMB No. 1545-0892
Expires: 9-30-88

Identity of Individual Conducting the Transaction

Last name First name Mi. Social security number
Number and street Passport number Country Alien registration number Couey
City State ZIP code Country (if not U.S.)} Other identifying data (Specify)
easy Individual or Organization for Whom This Transaction Was Completed

Individual’s last name

First name

Ml. Social security number

Name of organization

Employer identification number

Passport number Country

Number and street

Business or occupation

Alien registration number | Country

City State

ZIP code Country (if not U.S.)

Other identifying data (Specify)

Description of Transaction and Method of Payment

1 Amountofcashreceived. . .$

2 Amount in item 1 in $100 bills .

-$

3 Nature of transaction:

al personal property purchased .

oO
«Ol
dO
eO
ro
20
1

i C1 other (specity) >

real property purchased
personal services provided
business services provided
intangible property purchased
debt obligation paid
exchange of cash

escrowortrustfunds . . . .

Description of property or service

4 Method of payment by customer:
aC Paid withus. currency or coin
b C1 Paid with foreign currency (describe)

5 Date paid

Business Reporting This Transaction

Name of reporting business

Identification number (EIN or SSN)

Street address

Nature of your business

City

State ZIP code

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

Sign
Here”

(Authorized Signature—See Instructions)

Titley

(Date)

For Paperwork Reduction Act Notice, see page 2.

Form 8300 (Rev. 1-86)


Form 8300 (Rev. 1-86)

Page 2

General Instructions

Paperwork Reduction Act Notice.— We ask
for this information to carry out the Internal
Revenue laws of the United States. We need
it to ensure that taxpayers are complying with
these laws and to allow us to figure and
collect the right amount of tax. You are
required to give us this information

Who Must File.—Each person engaged ina
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. For other transactions that may be
related and special filing requirements for
installment payments, see section 1.6050 I-
1T of the regulations.

Certain precious metals dealers, precious
stones dealers, jewelry dealers, pawnbrokers,
loan or finance companies, insurance
companies and travel agencies must file Form
8300 when they have reportable cash
transactions. To the extent that the Assistant
Secretary of the Treasury (Enforcement and
Operations) requires these financial
institutions to file Form 4789, Currency
Transaction Report, Form 8300 is not required
to be filed for the same transaction(s).
Exceptions. —Financial institutions required
to file IRS Form 4789 under Section
5312(a)(2)(A), (B), (C), (D), (E), (F), (G), (I),
(K), (R), and (S) of Title 31, U.S.C., are
excepted from filing Form 8300. These
financial institutions include each agency,
branch, or office in the United States of any
person doing business in one or more of the
Capacities listed below
(1) a bank (see Definitions);

(2) a broker or dealer in securities, registered
or required to be registered with SEC
under the Securities Exchange Act of
1934;

(3) a person who engages as a business in
dealing in or exchanging currency (for
example, a dealer in foreign exchange or
a person engaged primarily in the cashing
of checks);

(4) a person who engages as a business
issuing, selling, or redeeming traveler's
checks, money orders, or similar
instruments, except one who does so as a
selling agent exclusively, or as an
incidental part of another business;

(5) a licensed transmitter of funds, or other
person engaged in the business of
transmitting funds abroad for others.

Transactions entirely occurring outside the
United States are excepted from these
reporting requirements, except as provided in
section 1.6050 1-1 T of the regulations. The
United States includes the 50 states and the
District of Columbia.

When and Where To File.—File this form by

the 15th day after the date of the transaction

with the Internal Revenue Service Data

Center, P.O. Box 32621, Detroit, MI 48232

ATTN: RCP or hand carry it to your local IRS

office. Keep a copy of each Form 8300 for 5

years from the date you file it.

Identifying Number.—For individuals this is

the social security number. For others it is the

Federal employer identification number (EIN),

which has 9 digits. For aliens or other non-
U.S. individuals, use the passport number or
alien registration number and indicate the
country.

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.

Statement To Be Provided.—A written
statement must be provided to each person
named in this form. The statement must be
provided 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 receiving
the cash and the total amount of cash
received during the year from the payer and
that the information is being furnished to the
IRS. Keep a copy for your records. A copy of
the Form 8300 that was filed with the Internal
Revenue Service may be used as the
statement if the payer had a single transaction
for the year.

Specific Instructions

Part I

This part must always be completed. If the
individual conducts the transaction for
another person, be sure to complete Part II
also.

In the address section, enter the permanent
street address of the individual conducting the
transaction.

In the social security block, enter the social
security number of the individual conducting
the transaction. If the individual has no
number, write “None” in this block.

If the individual is an alien or foreign
national, enter the alien registration number
or passport number and country or other
official documents evidencing nationality or
residence in the boxes provided.

Complete the “Other identifying data” box
for individuals other than aliens and foreign
nationals, Other identifying information
includes documents normally acceptable as a
means of identification when cashing checks
(e.g,, a driver's license or credit card number
may be entered in the “Other identifying data”
box provided).

Part Il

If the individual in Part | is conducting the
transaction for himself or herself, do not
complete Part Il. In all other cases, complete
Part ll.

For individuals, enter last name, first name,
middle initial, if any, and street address in the
boxes provided. For other than an individual,
enter the complete organization name,
address, and employer identification number
in the boxes provided.

In the social security block, enter the social
security number of the individual for whom
the transaction was completed. If the
individual has no number, write “None” in
this block.

If the individual is an alien or foreign
national, enter the alien registration number
or passport number and country or other
official documents evidencing nationality or
residence in the boxes provided.

Complete the “Other identifying data” box
for individuals other than aliens and foreign
nationals. Other identifying information
includes documents normally acceptable as a
means of identification when cashing checks
(eg., a driver's license or credit card number
may be entered in the “Other identifying data”
box provided).

Part Ill

Enter in item 2 the amount of U.S. currency
included in item 1 that is in $100 bills or
higher. (For example, if the amount in item 1
is $30,000, and $25,000 of it was paid in
$100 bills, enter $25,000 in item 2.)

Check the applicable boxes that describe
the nature of the transaction. Briefly describe
the kind of property or service for which the
customer paid cash.

If the aggregate amount of cash received in
two or more installment payments exceeds
$10,000, the date entered in item 5 should be
the date the payment is made that causes the
aggregate amount of cash to exceed $10,000.

Part IV

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

Definitions

Bank.—Each agent, agency, branch, or office
in the United States of a foreign bank and
each agency, branch, or office in the United
States of any person doing business in one or
more of the capacities listed below:

(1) acommercial bank or trust company
organized under the laws of any state or
of the United States;

a private bank;

a savings and loan association or a
building and loan association organized
under the laws of any state or of the
United States;

an insured institution as defined in section
401 of the National Housing Act;

a savings bank, industrial bank, or other
thrift institution;

a credit union organized under the laws of
any state or of the United States; and

any other organization chartered under
the banking laws of any state and subject
to the supervision of the bank supervisory
authorities of a state.

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 silver certificates,
United States notes, and Federal Reserve
notes, but does not include bank checks,
traveler's checks, or other negotiable or
monetary instruments not customarily
accepted as money.

Transaction in Cash.—A transaction
involving the physical receipt of cash froma
person. A transaction in cash does not include
a receipt of funds by means of bank check,
bank draft, wire transfer, or other written
order that does not include the physical
transfer of cash.

Transaction.—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
(for instance, a receipt of cash from a person
in exchange for a check); and the receipt of
cash to be held in escrow or trust.

(2)
(3)

(4)
(5)
(6)
(7)