Currency Transaction Report

Branch Albany Bend Cottage Grove Eugene Eugene Downtown Grants Pass Medford North Bend Oregon City Portland NE Halsey Roseburg Green Roseburg Kline Springfield Gateway Springfield Main Street Member Connect Member Solutions LSI Financial Suite Cedar Hills

Employee Name

Transaction Date

Transaction Time

Account Numbers

Total Cash Amount (including coin)

Transaction for benefit of: Member Non-Member Business Or Trust

Business Name or Trust Name

Type of Business

Transaction Type Check Cashed Deposit Withdrawal Payment
Payoff Night Drop Cash Exchange

Check Cashed Yes No
(if check was cashed, please email a copy of check to CTRPeeps@nwcu.com)

Credit Card Advance Yes No

Conductor Information

This information is required and is regarding the person who brought in the transaction. If any of the information in RED is withheld, please refuse the transaction and submit an Unusual Activity Report.

First Name

Middle Name (list None if person has no middle name)

Last Name

Social Security Number

Date of Birth

Person's Physical Street Address (not business or postal box address)

Person's City, State, Zip

Person's Phone Number

Person's Email Address (list None if person has no email address)

Occupation Status Employed Retired Unemployed Homemaker Other

Occupation & Employer (please be specific, both are required)

Prior Occupation (required if currently unemployed, retired, disabled, a homemaker, etc.)

ID Type (DL, State, Passport, etc.)

State of Issuer

ID Number

ID Expiration Date

Gender

Cash Information (if the person refuses to provide cash info., please indicate their reason)

Source of Cash Deposit

Purpose of Cash Withdrawal

Additional Comments or Transaction Details