This is an example of page 1, Form 8300, Report of Cash Payments Over $10,000 Received in a Trade or Business.Form 8300 Page 1 has the following Line 11 Check appropriate box(es): a Amends prior report; b Suspicious transactionPart I Identity of Individual From Whom the Cash Was Received2 If more than one individual is involved, check here and see instructions3 Last name4 First name5 M.I.6 Taxpayer identification number7 Address (number, street, and apt. or suite no.)8 Date of birth . . . (see instructions) MMDDYYYY9 City10 State11 Zip code12 Country (if not U.S.)13 Occupation, profession, or business14 Identifying document (ID)a Describe ID______________________________________b Issued by _______________________c Number_________________________________________Part II Description of Transaction and Method of Payment15 If this transaction was conducted on behalf of more than one person, check here and see instructions16 Individual’s last name or organization’s name17 First name18 M.I.19 Taxpayer identification number Employer Identification number Employer identification number20 Doing business as (DBA) name (see instructions)21 address (number, street, and apt. or suite no.)22 Occupation, profession, or Business23 City24 State25 Zip code26 Country (if not U.S.)27 Alien Identification (ID) a Description ID b issued by c numberPart III Description of Transaction and Method of Payments 28 Date cash received MMDDYYYY29 Total cash received $__________.0030 If cash was received in more than one payment check here31 Total price if different from item 29 $__________.0032 Amount of cash received (in U.S. dollar equivalent) (must equal item 29) (see instructions):a U.S. currency $___________.00 (Amount in $100 bills or higher $__________.00)b Foreign currency $___________.00 (Country___________________)c Cashier’s checks $___________.00 Issuers names(s) and serial number(s) of the monetary instrument(s)d Money orders(s) $___________.00 _____________________________________________________________________e Bank draft(s) $___________.00 _____________________________________________________________________f Traveler’s checks(s) $___________.00 _____________________________________________________________________33 Type of transactiona Personal property purchased b Real property purchasedc Personal services providedd Business services providede Intangible property purchasedf Debt obligations paidg Exchange of cashh Escrow or trust fundsI Bail received by court clerksj Other (specify in item 34)Specific description of property or service shown in33. Give serial or registration number, address, docket number, etc._____________________________________________________________________________________________________________________________________________Part IV Business That Received Cash35 Name of business that received cash35 Employer identification number37 Address (number, street, and apt. or suite no.)38 City39 State40 Zip Code41 Nature of your business42 Under penalties of perjury, I declare that to the best of my knowledge the information I have furnished above is true, correct, and complete.Signature Authorize Official__________________________________________Title _____________________________________________43 Date of Signature MMDDYYYY44 Type of print name of contact person45 Contact telephone number