Report of Cash Payments Over $10,000

Received in a Trade or Business Form 8300

OMB No. 1545-0892

(Rev. February 1992) Failure to file this form or filing a false form may result in imprisonment. Expires 09-30-94

Department of the Treasury © See instructions.

Internal Revenue Service Please type or print.

1 Check appropriate boxes if: a amends prior report; b suspicious transaction.

Identity of Individual From Whom the Cash Was Received

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

3 Last name 4 First name 5 Middle initial 6 Social security number

7 Address (number, street, and apt. or suite no.) 8 Occupation, profession, or business

9 City 10 State 11 ZIP code 12 Country (if not U.S.) 13 Date of birth (see instructions)

14 Method used to verify identity: a Describe identification ©

b Issued by 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 ©

16 This person is an: individual or organization 17 If funded by another party, see instructions and check here ©

18 Individual’s last name or Organization’s name 19 First name 20 Middle initial 21 Social security number

23 Alien identification: a Describe identification ©

Employer identification number

b Issued by c Number

24 Address (number, street, and apt. or suite no.) 25 Occupation, profession, or business

26 City 27 State 28 ZIP code 29 Country (if not U.S.) 30 Date of birth (see instructions)

Description of Transaction and Method of Payment

31a personal property purchased d business services provided g exchange of cash

b real property purchased e intangible property purchased h escrow or trust funds

c personal services provided f debt obligations paid i other (specify) ©

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

33 Total price $ .00 34 Amount of U.S. currency received $ .00 Amount in $100 bills or larger $ .00

37 If part of an installment sale, give information below and check box © 38 Date of transaction

a Number of payments b Amount of each payment $ .00

c Frequency: monthly other (describe) d Balloon payment (amount) $ .00

Business Reporting This Transaction

39 Name of reporting business 40 Employer identification number

41 Street address (number and street) where transaction occurred Social security number

42 City 43 State 44 ZIP code 45 Nature of your business

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

and complete.

46

Sign

Here

(Telephone number

of business)

(Authorized signature–See instructions) (Title) (Date signed)

(Type or print signer’s name below)

Cat. No. 62133S Form 8300 (Rev. 2-92)

Part IV

Part I

Part II

Part III

36a Amount of cash received in other than U.S. currency (see instructions)

b Specific description of cash received in other than U.S. currency

$ .00

35

22 Doing business as (DBA) name (see instructions)

( )
Continued—Complete if box 2 on page 1 is checked

3 Last name 4 First name 5 Middle initial 6 Social security number

7 Address (number, street, and apt. or suite no.) 8 Occupation, profession, or business

9 City 10 State 11 ZIP code 12 Country (if not U.S.) 13 Date of birth (see instructions)

14 Method used to verify identity: a Describe identification ©

b Issued by c Number

Continued—Complete if box 15 on page 1 is checked

16 This person is an: individual or organization 17 If funded by another party, see instructions and check here ©

18 Individual’s last name or Organization’s name 19 First name 20 Middle initial 21 Social security number

23 Alien identification: a Describe identification ©

Employer identification number

b Issued by c Number

24 Address (number, street, and apt. or suite no.) 25 Occupation, profession, or business

26 City 27 State 28 ZIP code 29 Country (if not U.S.) 30 Date of birth (see instructions)

Part I

Part II

22 Doing business as (DBA) name (see instructions)

Form 8300 (Rev. 2-92) Page 2

Multiple Parties

(Complete applicable parts below if box 2 or 15 on page 1 is checked)

3 Last name 4 First name 5 Middle initial 6 Social security number

7 Address (number, street, and apt. or suite no.) 8 Occupation, profession, or business

9 City 10 State 11 ZIP code 12 Country (if not U.S.) 13 Date of birth (see instructions)

14 Method used to verify identity: a Describe identification ©

b Issued by c Number

16 This person is an: individual or organization 17 If funded by another party, see instructions and check here ©

18 Individual’s last name or Organization’s name 19 First name 20 Middle initial 21 Social security number

23 Alien identification: a Describe identification ©

Employer identification number

b Issued by c Number

24 Address (number, street, and apt. or suite no.) 25 Occupation, profession, or business

26 City 27 State 28 ZIP code 29 Country (if not U.S.) 30 Date of birth (see instructions)

22 Doing business as (DBA) name (see instructions)
Form 8300 (Rev. 2-92) Page 3

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. 6050I.

The time needed to complete this form

will vary depending on individual

circumstances. The estimated average time

is 27 minutes. If you have comments

concerning the accuracy of this time

estimate or suggestions for making this

form more simple, you can write to both

the Internal Revenue Service,

Washington, DC 20224, Attention: IRS

Reports Clearance Officer T:FP, and the

Office of Management and Budget,

Paperwork Reduction Project (1545-0892),

Washington, DC 20503. DO NOT send this

form to either of these offices. Instead, see

When and Where To File below.

Changes You Should Note

Section 6050I of the Internal Revenue

Code was revised by the Revenue Act of

1990 to provide that, to the extent

provided by the regulations, the term

“cash” includes any monetary instrument,

whether or not in bearer form, with a face

amount of not more than $10,000 (other

than certain checks). The regulatory

change in the definition of cash is effective

for cash amounts received on or after

02/03/92. See the Definitions section of

these instructions and Regulations section

1.6050I-1 for more details.

General Instructions

Who Must File.—Each person engaged in

a trade or business who, during that 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.

Transactions are considered related even if

they occur over a period of more than 24

hours if the recipient knows, or has reason

to know, that each transaction is one of a

series of connected transactions. This form

may be filed voluntarily for any suspicious

transaction (see Definitions), 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 on 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 the initial payment

and subsequent payments made within 1

year. When the total exceeds $10,000, you

must file Form 8300 within 15 days. If

subsequent payments, alone or combined,

received within any 1-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 more than one report is

required to be filed within a 15-day period,

a single, combined report may be filed

Exceptions.—Regulations section

1.6050I-1 provides for exceptions to the

reporting requirements, including:

(1) Financial institutions required to file

Form 4789, Currency Transaction Report,

are exempt from filing Form 8300 for the

same transaction.

(2) Casinos required to file (or exempt

from filing) Form 8362, Currency

Transaction Report by Casinos, are exempt

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 in a cash transaction that is

reportable on Form 8300 or 4789, and (c)

discloses all the information necessary to

complete Part II 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 hand

carry it to 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.—You must

provide a written statement to each person

named in Form 8300 on or before January

31 of the year following the calendar year

in which the cash is received. 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.

Definitions

Person.—The term person means 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.

Recipient.—The term recipient generally

means the person receiving the cash. Each

store, division, branch, department,

headquarters, or office (“branch”)

(regardless of the physical location)

comprising a portion of a person’s trade or

business shall be a separate recipient.

However, a branch will not be considered

a separate recipient if the branch (or a

central unit linking such branch with other

branches) would in the ordinary course of

business have reason to know the identity

of payers making cash payments to other

branches of such person’s trade or

business.

Transaction.—The term transaction

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.

Cash—Amounts received before

02/03/92.—The term cash means 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.

Cash—Amounts received on or after

02/03/92.—The term cash means, in

addition to the above definition, a cashier’s

check, bank draft, traveler’s check, or

money order having a face amount of not

more than $10,000 received in a

Designated Reporting Transaction as

defined below, or received in any

transaction in which the recipient knows

that such instrument is being used in an

attempt to avoid the reporting of the

transaction under section 6050I.

Designated Reporting Transaction.—A

designated reporting transaction is a retail

sale (or the receipt of funds by a broker or

other intermediary in connection with a

retail sale) of:

● A consumer durable, which is an item of

tangible personal property of a type

suitable under ordinary usage for personal

consumption or use that can reasonably

be expected to be useful for at least 1 year

under ordinary usage, and that has a sales

price of more than $10,000.

● A collectible, which is any work of art,

rug, antique, metal, gem, stamp, or coin as

described in section 408(m)(2)(A) through

(D) without regard to section 408(m)(3).

● A travel or entertainment activity, which

is an item of travel or entertainment that

pertains to a single trip or event if the

combined sales price of the item and all

other items relating to the same trip or

event that are sold in the same transaction

(or related transactions) exceeds $10,000.

Retail Sale.—The term retail sale means

any sale (whether or not the sale is for

resale or for any other purpose) made in

the course of a trade or business if that

trade or business principally consists of

making sales to ultimate consumers.

Exceptions.—Unless the recipient knows

that it is being used in an attempt to avoid

instead. The combined report must be filed

no later than the due date for filing the first

report.) If subsequent payments, alone or

combined, received within 1 year do not

exceed $10,000, they need not be

reported.
Form 8300 (Rev. 2-92) Page 4

the reporting of the transaction, a cashier’s

check, bank draft, traveler’s check, or

money order received in a designated

reporting transaction is not treated as cash

if—

● The instrument constitutes the proceeds

of a loan from a bank (as defined in 31

CFR 103). The recipient may rely on a

copy of the loan document, a written

statement from the bank, or similar

documentation (such as a written lien

instruction from the issuer of the

instrument) to substantiate that the

instrument constitutes loan proceeds.

● The instrument is received in payment

on a promissory note or an installment

sales contract (including a lease that is

considered a sale for Federal income tax

purposes). However, the exception only

applies if the notes or contracts with the

same or substantially similar terms are

used in the ordinary course of your trade

or business in connection with sales to the

ultimate consumers and the total amount

of payments on the note or contract that

are received on or before the 60th day

after the date of the sale does not exceed

50% of the purchase price.

● The instrument is received under

payment plans requiring one or more down

payments and the payment of the balance

of the purchase price by the time of the

sale (in the case of an item of travel or

entertainment, the earliest date that any

item of travel or entertainment pertaining to

the same trip or event is furnished).

However, this only applies if you use plans

with the same or substantially similar terms

in the ordinary course of your trade or

business in connection with sales to

ultimate consumers; and the instrument is

received more than 60 days before the

date of sale (in the case of an item of

travel or entertainment, the date the final

payment is due).

Suspicious Transaction.—The term

suspicious transaction means a transaction

in which it appears that a person is

attempting to cause Form 8300 not to be

filed, or a false or incomplete form to be

filed, or where there is an indication of

possible illegal activity.

Specific Instructions

Complete all parts. Skip Part II if the

individual in Part I is conducting the

transaction on his or her behalf only.

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

1-800-800-2877.

Part I

Item 2.—If two or more individuals

conducted the transaction you are

reporting, check the box and complete Part

I on any one of the individuals. Provide the

same information on the other individual(s)

on the back of the form. If more than three

individuals are involved, provide the same

information on additional sheets of paper

and attach them to this form.

Item 6.—Enter the social security number

of the individual named. If the individual

has no number, enter “None.”

Item 8.—Use fully descriptive terms such

as plumber or attorney, and not

nondescriptive terms such as merchant,

businessman, or self-employed.

Item 13.—Enter six numerals for the date

of birth of the individual named. 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.

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 II

Item 15.—If the transaction is being

conducted on behalf of more than one

person (for example, if the individual in

Part I is buying a vehicle on behalf of two

persons), check the box and complete Part

II on any one of the persons. Provide the

same information requested in Part II on

the other person(s) on the back of the

form. If more than three persons are

involved, provide the same information on

additional sheets of paper and attach them

to this form.

Item 16.—If the person named 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 I or II. Provide the same

information on that party or parties on

additional sheets of paper and attach them

to this form.

Items 18 through 21.—If the person on

whose behalf the transaction was

conducted is an individual, complete items

18, 19, and 20. Enter his or her social

security number (SSN) in item 21 (enter

“None” if the person does not have one). If

the individual is a sole proprietor and has

an employer identification number (EIN),

enter both the SSN and EIN in item 21. If

the person is an organization, put its name

in item 18 and its EIN in item 21. If it does

not have an EIN, enter “None” in item 21.

Item 22.—If a sole proprietor or other

organization named in items 18–20 is

doing business as (DBA) under a name

other than that entered in items 18–20,

enter the DBA name here.

Item 23.—If the person is an alien without

an SSN, complete this item. Enter a

general description of the type of official

document issued to that person in item

23a (e.g., “passport”), the country that

issued the document in item 23b, and the

document’s number in item 23c.

Item 30.—See item 13 instructions.

Part III

Item 31.—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 33 through 36b.—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 33. Enter the total

amount of U.S. currency received

reportable on this return (see Multiple

Payments for reporting requirements) in

item 34 and the amount of $100 (and

larger) bills in item 35. Show only nearest

dollar amounts. Round 50 cents or more to

the next whole dollar.

Enter in item 36a the amount of all

cashier’s check(s), bank draft(s), traveler’s

check(s), and/or money order(s) each

having a face amount of not more than

$10,000 and any currency and/or coin of

another country received. See the

definitions of Cash. Provide a specific

description of these items in 36b. This

should include the name of the issuer, date

issued, amount and number of each

cashier’s check, bank draft, traveler’s

check, and/or money order plus the

country of issuance and amount (in U.S.

dollar equivalent) of any currency and/or

coin of another country. If more space is

required enter the information required by

item 36b on additional sheets of paper and

attach them to this form.

Item 37.—If the transaction is part of an

installment sale, check the box. In item

37a, enter the number of payments agreed

upon; in item 37b, enter the amount of

each installment payment; in item 37c,

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 or semi-annually). If the installments

are for different amounts, attach a

schedule.

Item 38.—If the combined amount of cash

received in two or more installment

payments exceeds $10,000, enter the

payment date that causes the combined

amount to exceed $10,000. Also, see

Multiple Payments.

Part IV

Item 40.—Enter the EIN of the reporting

business. Enter your SSN only if your

business has no EIN.

Item 45.—Describe the nature of the

business filing the report. Use descriptive

terms (auto dealer, jewelry dealer) rather

than nondescriptive terms (business,

store).

Item 46.—This report must be signed by

an authorized individual. Also type or print

the name of the signer below the signature

and enter the telephone number of the

business filing the report.