Introductory BSA/AML Examiner School, Providence, RI
WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION AND WILL NOT BE PROCESSED BY FinCEN.
PartIPersonInvolvedinTransaction3of3 *2 Person conducting transaction on own behalf Person conducting transaction for another
Person on whose behalf
Courier service (private)
transaction is conducted
3
Multiple transactions
Check If entity *4 Individual's last name or entity's legal name
Unknown BUTLER
*5 First name 6 Middle name
Unknown KENNETH
W
Suffix 7 Gender 8 Alternate Name 9 Occupationor type of business
CLASSIC CAR RESTORER
9a NAICSCode *10 Address
Unknown 40 COUNTRYVIEWLN
*11 City
Unknown OROVILLE
*12 State
*13 ZIP/Postal Code
Unknown CA
Unknown 95966
*14 Country
Unknown US
*15 TIN
16 TINtype
Unknown 557139231
SSN/ITIN
*17 Date of birth Unknown 11/27/1957 18 Contact phone number Ext. 19 E-mail address *20 Formof identificationused toverify identity
Unknown
Passport Alien registration Other
Driver's license/State ID
Number
Country
IssuingState
N3779367 CA 21 Cash inamount for individual or entity listed in Item4 $ 4670.00 Account number 22 Cashout amount for individual or entity listed in Item4 $ 0.00 Account number US
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