EFTA01291931.pdf

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Currency Transaction Report Version Number 1.1
OMB No. 1506-0064
Filing Name 152-5244
'1 Type of filing Z Initial report q Corredsmend prior report q FinCEN directed Backfiling
Document Control Number / BSA Identifier
J
Save Validate Print
Under penalties of perjury. I declare that I have examined this transmittal, including accompanying
documents, and to the best of my knowledge and belief it is correct and complete. In the case of documents
without recipients identifying numbers, I have complied with the requirements of the law in attempting to
secure such numbers from the receipts. I declare that this filing represents all Documents filed during this
reporting period except for those transactions reported on paper.
Sign with PIN
SDNY_GM_00049857
IDENTIAL
CONFIDENTIAL - PURSUANT TO FED. R.CON(F DB-SDNY-0012681
EFTA_00160465
EFTA01291931

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Part 1 Person Involved in Transaction 1 of 2 00
a Person conducting Person conducting pvl Person on whose behalf q
I q —I transaction on own behalf b transaction for another ® transaction was conducted d Courier Service (private)
3 q Multiple transactions
Check q If entity
'4 Individuabs last name q
Unknown Epstein
or entilys legal name
'5 First name q Unknown Jeffrey
6 Middle name
Suffix
7 Gender Male
8 Alternate Name
9 Occupation or type of business
9a NAICS Code
'10 Address q Unknown 6100 Red Hook quarter 83
'11 City q Unknown IST. Thomas
'12 State ❑Unknown VI '13 ZIP/Postal Code q Unknown
'14 Country q Unknown I. US
'5 TIN q Unknown 18 TIN type SSNJTIN
'17 Date of birth q Unknown 0112011963
18 Contact phone number Ext.
19 E-mail address
'20 Form of identification used to verify identity Ei Unknown
q
q Drivers ecense/State ID q Passpon q Alien Registration Other
Number Country Issuing State
2t Cash in amount for individual or entity listed in Item 4
I 00
Account number
22 Cash out amount for Individual or entity listed in Item 4 $ 21.160
0
Account number[
Page 2 of 5
SDNY_GM_00049858
IDENTIAL
CONFIDENTIAL - PURSUANT TO FED. R.CON(F DB-SONY-00 12682
EFTA_00160466
EFTA01291932

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Part 1 Person Involved in Transaction 2 of 2 00
a O Person conducting Person conducting Person on whose behalf q
'2 Courier
transaction on own behalf b law transaction for another c O transaction was conducted d Service (Private)
3 O Multiple transactions
Check q If entity
'4 Individual's last name
O Unknown Beller
or entity's legal name
'5 First name O Unknown Harry
6 Middle name
Suffix
7 Gender Male
8 Alternate Name
9 Occupation or type of business Accountant
9a NAICS Code 6412
'10 Address O Unknown 12 Golar Dr
•11 City O Unknown Monsey
•12 State O Unknown NY '13 ZIP/Postal Code 0 Unknown 10952
'14 Country O Unknown I. US
'15 TIN 0 Unknown 16 TIN type SSN4TIN
'17 Date of birth 0 Unknown
18 Contact phone number Ext.
19 E-mail address
'20 Form of identification used to verify identity OUnknown
IX Drivers kcense/State ID O Passport O Alien Registration O Other
Number Country US Issuing State NY
21 Cash in amount for individual or entity listed in Item 4 $
0 0
Account number
22 Cash out amount for irxhvidual or entity listed in Item 4 21.150
Account number a
Page 3 of 5
SDNY_GM_00049859
IDENTIAL
CONFIDENTIAL - PURSUANT TO FED. R.CON(F DB-SONY-00 12683
EFTA_00I60467
EFTA01291933

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Part II Amount and Type of Transaction(s). Check all boxes that apply.
'23 Date of transaction 12J19!2013
24 q Armored car (FI Contract) q ATM q Mail Deposit or Shipment q Night Deposit q Aggregated transactions
•25 CASH IN: (in U.S. dollar equivalent) '27 CASH OUT: (In U.S. dollar equivalent)
a Deposit(s) a Inathdrawal(s)
b Payrnant(s) .00 b Advance(s) on aedit (Including markers) .00
c Currency received for funds
transfor(s) out .00 c Currency pad horn funds trander(s) In .00
d Purchase of negotiable instrument (a) .00 d Negotiable instrumen(s) cashed .00
e Currency oxchange(s) 00 e Currency exchange(s) 21,160.00
I Currency to prepaid access .00 f Currency from prepaid access .00
g Purchases of casinos chips, tokens a Redemphon(s) of casino chips. tokens.
and other gaming instruments 00 TITO tickets end other gaining Instruments 00
h Currency wager(s) ecluding h Pa/mantis) on wagerts) (Including race
money pay's .00 and OTB or spans pool) .00
I Travel and complimentary expenses and
I Bills inserted irnogarniag devices .00 book gaming Incentives .00
I Payment for tournament, contest or other
t Other (specify): promotions .00
z Other (specify)
.00
.00
Total Cash in .00 Total Cash out 21,16000
0 0
26 Foreign Cash in Foreign Country
0 0
28 Foreign Cash out 16,100 Foreign Country BE
Page 4 of 5
SDNY_GM_00049860
IDENTIAL
CONFIDENTIAL - PURSUANT TO FED. R.CON(F DB-SONY-00 12684
EFTA_00I 60468
EFTA01291934

WARNING: PRINTED VERSIONS OF THE BSA E-FILING FORMS ARE NOT FOR SUBMISSION
AND WILL NOT BE PROCESSED BY FINCEN.
Part III Financial Institution Where Transaction(s) Takes Place 1 of 1 0 0
'37 Type of financial institution Depository institution
Other (specify)
'29 Primary federal regulator Federal Reserve Board (FRB)
38 If 37a - Casino/Card Club is checked, indicate type (chedc only one)
q State licensed casino q Tribal authorized casino 0 Card club q Other
'30 Legal name of financial institution Deutsche Bank Trust Company Americas
31 Alternate name, e.g. trade name, DBA
'32 EIN
'33 Address 346 Park Ave
'34 City New York
'35 Slate NY
'36 ZIP Code j10154
39 Financial institution 10 type
ID number
'40 Contact office DB PB AML
'41 Phone number Ext.
'42 Date Filed (Dale filed will be aut-opopulated when des form is signed.)
Page 5 of 5
SDNY_GM_00049861
IDENTIAL
CONFIDENTIAL - PURSUANT TO FED. R.CON(F DB-SONY-0012685
EFTA_00160469
EFTA01291935