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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) 2

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

CABELL

*5 First name

Unknown

ASHLEIGH

6 Middle name

Suffix

7 Gender 8 Alternate name

Female

GAS STATION CLERK

9 Occupation or type of business

9a NAICS Code

Unknown 1789 GREEN GATE WAY 12 COUNTRY CLUB LANE

* 10 Address

Unknown OMAHA

* 11 City

Unknown

Unknown 68509

* 13 ZIP/Postal Code

* 12 State

NE

Unknown

US

*14 Country

Unknown 810-36-6541

SSN-ITIN

16 TIN type

* 15 TIN

Unknown 09/18/1995

*17 Date of birth

402-696-2323

18 Contact phone number

Ext.

19 E-mail address

* 20 Form of identification used to verify identity

Unknown

Driver's license/State ID

Passport

Alien Registration

Other

G102497787

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

63325

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

$

+ -

Account number

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