Customs Form 4790 (031695)

Form Approved
OMB No. 1515-0079
DEPARTMENT OF THE TREASURY
UNITED STATES CUSTOMS SERVICE
(U.S. Customs Use Only)
This form is to be filed with the
United States Customs Service
REPORT OF INTERNATIONAL
TRANSPORTATION OF CURRENCY
OR MONETARY INSTRUMENTS
Control No.
31 U.S.C. 5316; 31 CFR 103.23 and 103.25
Please type or print.
For Paperwork Reduction Act
Notice and Privacy Act Notice,
see back of form.
Part I FOR INDIVIDUAL DEPARTING FROM OR ENTERING THE UNITED STATES
1. NAME (Last or family, first, and middle)
2. IDENTIFYING NO. (See instructions)
3. DATE OF BIRTH (Mo./Day/Yr.)
4. PERMANENT ADDRESS IN UNITED STATES OR ABROAD
5. OF WHAT COUNTRY ARE YOU A
CITIZEN/SUBJECT?
6. ADDRESS WHILE IN THE UNITED STATES
7. PASSPORT NO. & COUNTRY
8. U.S. VISA DATE
10. IMMIGRATION ALIEN NO. (If any)
9. PLACE UNITED STATES VISA WAS ISSUED
11. CURRENCY OR MONETARY INSTRUMENT WAS: (Complete 11A or 11B)
A. EXPORTED
Departed From: (City in U.S.)
Part II
B. IMPORTED
Arrived At: (Foreign City/Country)
From: (Foreign City/Country)
At: (City in U.S.)
FOR PERSON SHIPPING, MAILING, OR RECEIVING CURRENCY OR MONETARY INSTRUMENTS
12. NAME (Last or family, first, and middle)
13. IDENTIFYING NO. (See instructions)
14. DATE OF BIRTH (Mo./Day/Yr.)
15. PERMANENT ADDRESS IN UNITED STATES OR ABROAD
16. OF WHAT COUNTRY ARE YOU
A CITIZEN/SUBJECT?
17. ADDRESS WHILE IN THE UNITED STATES
18. PASSPORT NO. & COUNTRY
19. U.S. VISA DATE
21. IMMIGRATION ALIEN NO. (If any)
20. PLACE UNITED STATES VISA WAS ISSUED
23. CURRENCY OR
MONETARY
INSTRUMENTS
22. CURRENCY OR
MONETARY
INSTRUMENTS
DATE SHIPPED
NAME AND ADDRESS
24. IF THE CURRENCY OR MONETARY INSTRUMENT WAS
MAILED, SHIPPED, OR TRANSPORTED COMPLETE
BLOCKS A AND B.
A. Method of Shipment (Auto, U.S. Mail, Public Carrier, etc.)
Shipped
To
B. Name of Transporter/Carrier
DATE RECEIVED
Received
From
Part III
CURRENCY AND MONETARY INSTRUMENT INFORMATION (SEE INSTRUCTIONS ON REVERSE)(To be completed by everyone)
25. TYPE AND AMOUNT OF CURRENCY/MONETARY INSTRUMENTS
Value in U.S. Dollars
Coins
A.
Currency
B.
$
26. IF OTHER THAN U.S. CURRENCY
IS INVOLVED, PLEASE COMPLETE
BLOCKS A AND B. (SEE SPECIAL
INSTRUCTIONS)
A. Currency Name
Other Instruments (Specify Type)
C.
TOTAL
AMOUNT
(Add lines A, B and C)
Part IV
B. Country
$
GENERAL - TO BE COMPLETED BY ALL TRAVELERS, SHIPPERS, AND RECIPIENTS
27. WERE YOU ACTING AS AN AGENT, ATTORNEY OR IN CAPACITY FOR ANYONE IN THIS
CURRENCY OR MONETARY INSTRUMENT ACTIVITY? (If "Yes" complete A, B and C)
A. Name
B. Address
Yes
No
C. Business activity, occupation, or profession
PERSON IN
WHOSE BEHALF
YOU
ARE ACTING
Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief it is true, correct and complete.
28. NAME AND TITLE
29. SIGNATURE
(Replaces IRS Form 4790 which is obsolete.)
30. DATE
Customs Form 4790 (031695)
GENERAL INSTRUCTIONS
This report is required by Treasury Department regulations (31 Code of Federal Regulations 103).
Who Must File.--Each person who physically transports, mails, or ships, or causes to be physically transported, mailed, shipped or received currency or other monetary
instruments in an aggregate amount exceeding $10,000 on any one occasion from the United States to any place outside the United States, or into the United States from
any place outside the United States.
A TRANSFER OF FUNDS THROUGH NORMAL BANKING PROCEDURES WHICH DOES NOT INVOLVE THE PHYSICAL TRANSPORTATION OF CURRENCY OR
MONETARY INSTRUMENTS IS NOT REQUIRED TO BE REPORTED.
Exceptions.--The following persons are not required to file reports: (1) a Federal Reserve bank, (2) a bank, a foreign bank, or a broker or dealer in securities in respect to
currency or other monetary instruments mailed or shipped through the postal service or by common carrier, (3) a commercial bank or trust company organized under the
laws of any State or of the United States with respect to overland shipments of currency or monetary instruments shipped to or received from an established customer
maintaining a deposit relationship with the bank, in amounts which the bank may reasonably conclude do not exceed amounts commensurate with the customary conduct
of the business, industry, or profession of the customer concerned, (4) a person who is not a citizen or resident of the United States in respect to currency or other
monetary instruments mailed or shipped from abroad to a bank or broker or dealer in securities through the postal service or by common carrier, (5) a common carrier of
passengers in respect to currency or other monetary instruments in the possession of its passengers, (6) a common carrier of goods in respect to shipments of currency or
monetary instruments not declared to be such by the shipper, (7) a travelers’ check issuer or its agent in respect to the transportation of travelers’ checks prior to their
delivery to selling agents for eventual sale to the public, nor by (8) a person engaged as a business in the transportation of currency, monetary instruments and other
commercial papers with respect to the transportation of currency or other monetary instruments overland between established offices of banks or brokers or dealers in
securities and foreign persons.
WHEN AND WHERE TO FILE:
A. Recipients.--Each person who receives currency or other monetary instruments shall file Form 4790, within 30 days after receipt, with the Customs officer in charge at
any port of entry or departure or by mail with the Commissioner of Customs, Attention: Currency Transportation Reports, Washington DC 20229.
B. Shippers or Mailers:--If the currency or other monetary instrument does not accompany the person entering or departing the United States, Form 4790 may be filed by
mail on or before the date of entry, departure, mailing, or shipping with the Commissioner of Customs, Attention: Currency Transportation Reports, Washington DC 20229.
C. Travelers.--Travelers carrying currency or other monetary instruments with them shall file Form 4790 at the time of entry into the United States or at the time of
departure from the United States with the Customs officer in charge at any Customs port of entry or departure.
An additional report of a particular transportation, mailing, or shipping of currency or the monetary instruments, is not required if a complete and truthful report has already
been filed. However, no person otherwise required to file a report shall be excused from liability for failure to do so if, in fact, a complete and truthful report has not been
filed. Forms may be obtained from any United States Customs Service office.
PENALTIES.--Civil and criminal penalties, including under certain circumstances a fine of not more than $500,000 and imprisonment of not more than five
years, are provided for failure to file a report, supply information, and for filing a false or fraudulent report. In addition, the currency or monetary instrument
may be subject to seizure and forfeiture. See section 103.47, 103.48 and 103.49 of the regulations.
DEFINITIONS:
Bank.--Each agent, agency, branch or office within the United States of a foreign bank and each agency, branch or office within the United States of any person doing
business in one or more of the capacities listed: (1) a commercial bank or trust company organized under the laws of any state or of the United States; (2) a private bank;
(3) a savings and loan association or a building and loan association organized under the laws of any state or of the United States; (4) an insured institution as defined in
section 401 of the National Housing Act; (5) a savings bank, industrial bank or other thrift institution; (6) a credit union organized under the laws of any state or of the
United States; and (7) any other organization chartered under the banking laws of any state and subject to the supervision of the bank supervisory authorities of a state.
Foreign Bank.--A bank organized under foreign law, or an agency, branch or office located outside the United States of a bank. The term does not include an agent,
agency, branch or office within the United States of a bank organized under foreign law.
Broker or Dealer in Securities.--A broker or dealer in securities, registered or required to be registered with the Securities and Exchange Commission under the
Securities Exchange Act of 1934.
IDENTIFICATION NUMBER.--Individuals must enter their social security number, if any. However, aliens who do not have a social security number should
enter passport or alien registration number. All others should enter their employer identification number.
Investment Security.--An instrument which: (1) is issued in bearer or registered form; (2) is of a type commonly dealt in upon securities exchanges or markets or
commonly recognized in any areas in which it is issued or dealt in as a medium for investment; (3) is either one of a class or series or by its terms is divisible into a class
or series of instruments; and (4) evidences a share, participation or other interest in property or in an enterprise or evidences an obligation of the issuer.
Monetary Instruments.--Coin or currency of the United States or of any other country, travelers’ checks, money orders, investment securities in bearer form or otherwise
in such form that title thereto passes upon delivery, and negotiable instruments (except warehouse receipts or bills of lading) in bearer form or other in such form that title
thereto passes upon delivery. The term includes bank checks, travelers’ checks and money orders which are signed but on which the name of the payee has been
omitted, but does not include bank checks, travelers’ checks or money orders made payable to the order of a named person which have not been endorsed or which bear
restrictive endorsements.
Person.--An individual, a corporation, a partnership, a trust or estate, a joint stock company, and association, a syndicate, joint venture or other unincorporated
organization or group, and all entities cognizable as legal personalties.
SPECIAL INSTRUCTIONS:
You should complete each line which applies to you. Part II.--Line 22, enter the exact date you shipped or received currency or monetary instrument(s). Line 23, check
the applicable box and give the complete name and address of the shipper or recipient. Part III.--Line 26, if currency or monetary instruments of more than one country is
involved, attach a schedule showing each kind, country, and amount.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on Form 4790 in accordance with
5 U.S.C. 552a(e)(3) is Public Law 91-508; 31 U.S.C. 5316; 5 U.S.C. 301; Reorganization Plan No. 1 of 1950; Treasury Department No.165, revised, as amended; 31 CFR 103;
and 44 U.S.C. 3501.
The principal purpose for collecting the information is to assure maintenance of reports or records where such reports or records have a high degree of usefulness in criminal, tax, or
regulatory investigations or proceedings. The information collected may be provided to those officers and employees of the Customs Service and any other constituent unit of the
Department of the Treasury who have a need for the records in the performance of their duties. The records may be referred to any other department or agency of the Federal
Government upon the request of the head of such department or agency.
Disclosure of this information is mandatory. Failure to provide all or any part of the requested information may subject the currency or monetary instruments to seizure and forfeiture,
as well as subject the individual to civil and criminal liabilities.
Disclosure of the social security number is mandatory. The authority to collect this number is 31 CFR 103.25. The social security number will be used as a means to identify the
individual who files the record.
The collection of this information is mandatory pursuant to 31 U.S.C. 5316.
Statement Required by 5 CFR 1320.21: The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper depending on
individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs Service,
Paperwork Management Branch, Washington DC 20229. DO NOT send completed form(s) to this office.