BSA-AML Examiner School Case Study eBook

Internal Use Only This form has bee signed and cannot be altered.

Currency Transaction Report

Step 3. Person(s) Involved Information

Step 4. Amount and Type of Transaction(s)

Step 2. Transaction Location(s) Information

Step 1. Filing Institution Contact Information

Home

Part I Person Involved in Transaction(s) 1

of

+ -

2

Person on whose behalf transaction was conducted

Person conducting transaction on own behalf

Person conducting transaction for another

*2

Common carrier

a

c

d

b

3

Multiple transactions

Check *4 Individual's last name or entity's legal name

If entity

Unknown

NORTHERN FUEL II LLC

*5 First name

Unknown

6 Middle name

Suffix

7 Gender 8 Alternate name

GAS STATION

9 Occupation or type of business

9a NAICS Code

Unknown

* 10 Address

12 COUNTRY CLUB LANE

Unknown

* 11 City

OMAHA

Unknown

Unknown

68509

* 13 ZIP/Postal Code

* 12 State

NE

Unknown

*14 Country

US

Unknown

EIN

16 TIN type

15-8455266

* 15 TIN

Unknown

*17 Date of birth

555-121-8321

3077550781

18 Contact phone number-

Ext.

TACABELL@YAHOO.COM

19 E-mail address

* 20 Form of identification used to verify identity

Unknown

Driver's license/State ID

Passport

Alien Registration

Other

SOS NUMBER

12452410

Number

NE

Issuing State

US

Country

21 Cash in amount for individual or entity listed in Item 4

$

13,836

+

-

575010815 10 3325

Account number

22 Cash out amount for individual or entity listed in Item 4

$

+ -

Account number

This form has been signed and cannot be altered.

Page 4 of 6