Contaminated Currency Notification Form

CASH-04
INTERNAL FR
(Upon receipt by the Federal Reserve Banks)
Contaminated Currency Notification Form
Required Fields*
Section 1: Service Description and Form Instructions
The FedCash® Services Contaminated Currency form can be used to provide advance written notification to
your local Federal Reserve Bank of an incoming deposit containing contaminated currency.
For additional information and details, review the Contaminated Currency Procedures.
For assistance completing this form, please consult your local FedCash Services contact.
Please complete the following information and fax or e-mail to the servicing Federal Reserve Bank.
Contact your local Federal Reserve to obtain fax telephone numbers and e-mail addresses.
Section 2: Customer Information
Institution Name *
Identification Number (ABA/RTN) *
Requesting Contact Name *
Requesting Contact Phone Number *
9-Digit ABA Number
4-Digit Branch Number
First
Country Code
MI
Phone
Last
Extension
Requesting Contact Email Address *
Section 3: Customer Specific Requests
Today’s Date *
Expected Date of Federal Reserve
Bank Deposit *
Total Amount *
Armored Carrier Name *
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CASH-04
INTERNAL FR
(Upon receipt by the Federal Reserve Banks)
3.1 Contaminated Currency Denomination
Contaminated Currency
Denomination
Breakdown Amount
$1
$2
$5
$10
$20
$50
$100
Total:
3.2 Type of Contaminated Currency
Blood or other bodily secretion
Chemical/red dye-pack
Sewage
Please check all that apply
Visible mold/mildew
Wet or damp currency
Other
If Other, explanation required
Contaminated currency is defined as currency that has been damaged by or exposed to contaminants, poses
a health hazard or safety risk, and cannot be processed under normal operating procedures. In general,
contamination may be caused by the following:
 Floodwater or any prolonged exposure to water or other liquids
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CASH-04
INTERNAL FR
(Upon receipt by the Federal Reserve Banks)
 Exposure to blood, urine, feces or any other bodily fluids, including removal from any body cavity, corpse or
animal
 Exposure to sewage, mold or mildew
 Exposure to any foreign substance or chemical, including dye-packs, which may pose a health hazard or
safety risk
Refer to FRBservices.org for the proper packaging requirements for all contaminated currency deposits.
The Financial Services logo and "Fed Cash" are registered trademarks or service marks of the Federal Reserve Banks. A complete list of marks owned
by the Federal Reserve Banks is available at FRBservices.org.
Last updated: 06/20/2016
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