BSA/AML Examiner School - Case Study Oct 2023

This form has been 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 conducting transaction on own behalf

Person on whose behalf transaction was conducted

Person conducting transaction for another

*2

Common carrier

a

b

c

d

3

Multiple transactions

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

If entity

Unknown

BLUE PARKWAY EZ STOP

*5 First name

Unknown

6 Middle name

Suffix

7 Gender 8 Alternate name

GAS STATION

9 Occupation or type of business

457120

9a NAICS Code

Unknown

* 10 Address

112 MAIN STREET

Unknown

* 11 City

FT. LAUDERDALE

Unknown

Unknown

55555-9409

* 13 ZIP/Postal Code

* 12 State

TN

Unknown

*14 Country

US

Unknown

EIN

16 TIN type

11-8531131

* 15 TIN

Unknown

*17 Date of birth

555-853-3111

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

SOS ID NUMBER

10222238

Number

TN

Issuing State

US

Country

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

$

+ -

7094126

Account number

12,000

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

$

+ -

1014001

Account number

This form has been signed and cannot be altered.

Page 4 of 6