Funds Transaction Report (FTR)

NOTICE TO CUSTOMER: By federal law, the United States Postal Service® is required to obtain information from the purchaser of money orders, wire
transfers, and stored value cards when the dollar amount of cash purchases total $3,000 or more (31 USC 5325 and 5331). Multiple purchases during
one business day totaling $3,000 or more must be treated as one purchase, and the information must be obtained if a Postal Service™ employee knows
or has reason to believe that multiple purchases are being made. Postal Service policy also requires information to be obtained for cash purchases
of wire transfers and stored value cards between $1,000 and $3,000. Additionally, federal law requires the Postal Service to obtain information from
persons who redeem/cash money orders totaling more than $10,000 during the same day.
Privacy Act Statement: Your information will be used to fulfill requirements of anti-money laundering statutes and regulation issues. Collection is
authorized by 39 USC 401, 403, 404 and, 31 USC 5318, 5325, 5331, and 7701. Providing the information is voluntary, but if not provided, we may not
process your transaction. We do not disclose your information without your consent to third parties, except to facilitate the transaction, to act on your
behalf or request, or as legally required. This includes the following limited circumstances: to a congressional office on your behalf; to financial entities
regarding financial transaction issues; to an auditor, internal or external to the Postal Service; to entities, including law enforcement, as required by law or
in legal proceedings; and to contractors and other entities aiding us to fulfill the service. For more information on our privacy policies see our privacy link
on usps.com®.
Please print when completing form.
I. Completed by Customer Conducting Transaction(s)
Last Name First Name

000000000000000 00000000000000
Address (Number, Street, Box, Suite/Apt. No.)

000000000000000000000000000000
City   State  ZIP+4® Country

0000000000000 00  0 0 0000  00 

0 000
Date of Birth (MM/DD/YYYY) Social Security Number/EIN/TIN   Telephone Number (include area code)

00 00 0000 000000000    

/ / 0 
0  00000000
Driver’s License No. (U.S. Only) State

00000000000000000000 00
  
Photo ID
Required
Resident Alien/Permanent Resident ID No. Passport No. Country

0000000000   0000000000   
Occupation (Required)
000
     
  Military ID No. (U.S. Only)
Round Date Stamp

000000000000000   0000000000 Type of Other ID (U.S. Government-issued IDs

Other ID No. (Type of ID Required) and Mexican Matricula Consular.)

0000000000     
000000000000000
II. Completed by Postal Service Employee

 0000000
Type of Transaction (Check one):
Total Face value (Excluding fee):   $

£ Purchased ($3,000.00 or more) £ Redeemed/Cashed (over $10,000.00)

Transaction Date: 00 00 0000 / /

List additional transaction numbers for money orders, funds transfer Sure Money™/Dinero Seguro, and gift cards on the back of this form.
Begin Serial No. Thru End Serial No.
Money Order
Range 1: 00000000000 00000000000
Money Order
Range 2:
Number of
00000000000 00000000000
Number of Number of
Money Orders
Sold: 000 000   
000
Money Orders
Redeemed/Cashed:
Gift Cards
Sold:

Funds Transfer 1:
 
000000000000000
Sure Money/Dinero Seguro
 Post Office ZIP
Mail this form daily to:
USPS BSA COMPLIANCE
I certify that I have verified the personal information for the customer

   
00000
PO BOX 5214
by examining the photo ID noted.
JANESVILLE WI 53547-5214
Signature of USPS
Employee
PS Form 8105-A, October 2014 Page 1 of 2 (PSN: 7530-04-000-0302)
 Funds Transaction Report (FTR) — continued
II. Completed by Postal Service Employee -- continued

Money Order
Begin Serial No. Thru End Serial No.
Money Order
Range 3: 00000000000 00000000000
Begin Serial No. Thru End Serial No.
Money Order
Range 4: 00000000000 00000000000

Gift Card Serial Number

Gift Card 1: 

000000000000000000000000000000
Gift Card 2: 
000000000000000000000000000000
Gift Card 3: 
000000000000000000000000000000
Gift Card 4: 
000000000000000000000000000000
Gift Card 5: 
000000000000000000000000000000
Gift Card 6: 
000000000000000000000000000000

Funds Transfer Transaction Number

Funds Transfer 2:
Sure Money/Dinero Seguro 000000000000000
Funds Transfer 3:
Sure Money/Dinero Seguro 000000000000000
Funds Transfer 4:
Sure Money/Dinero Seguro 000000000000000
Funds Transfer 5:
Sure Money/Dinero Seguro 000000000000000

PS Form 8105-A, October 2014 (Page 2 of 2)