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SENSITIVE (when complete)

Cross-Border 530615 PART A DETAILS OF PERSON CARRYING THE


CURRENCY INTO OR OUT OF AUSTRALIA
Movement - 1 Full name of person carrying the currency (given & surnames)

Physical
Currency 2 Business/residential address in home country (not a P.O. Box)

$10,000 or more
CARRYING CURRENCY INTO
OR OUT OF AUSTRALIA
State

Complete this form if you are moving AUD10,000 or more of physical Postcode
currency (or the equivalent in foreign physical currency). Physical Country
(if not Australia)
currency is defined in the AML/CTF Act as the coin and printed
money of a country but does not include traveller's cheques and/or Phone No
other monetary instruments.
3 Are you an Australian resident?
Please complete this form in black ink and print in CAPITAL
LETTERS. Mark appropriate answer boxes with a cross (X). Yes No Please specify your address while in Australia
Give the completed form to a customs or police officer at any
Australian air or sea port at the time of your arrival or departure.
For further information visit www.austrac.gov.au or telephone the
AUSTRAC Contact Centre on 1300 021 037. State Postcode

Phone No

Privacy Notice 4 Occupation, business or principal activity


Cross-border movements of AUD10,000 or more of physical currency (or
the equivalent in foreign physical currency) must be reported to AUSTRAC
under the Anti-Money Laundering and Counter-Terrorism Financing Act ACN, ABN or ARBN
2006 (AML/CTF Act).
AUSTRAC protects personal information provided to it, as required by the 5 Date of birth D D MM Y Y Y Y
Privacy Act 1988 (Privacy Act). Collection of information in this form is
authorised by the AML/CTF Act, AML/CTF Rules and the Privacy Act and 6 Place of Birth
is used for those Acts and the Financial Transaction Reports Act 1988. Town or City
AUSTRAC discloses personal information to the agencies and entities
covered by Part 11 of the AML/CTF Act, including authorised overseas Country
recipients.
7 Give details of all valid passports or other travel documents that you
AUSTRAC's Privacy Policy at: hold
www.austrac.gov.au/about-us/using-our-website/austrac-privacy-policy
Passport no.
sets out other information required by the Privacy Act. 1.
Country of issue

Passport no.
2.
Country of issue

OFFICE USE ONLY 8 Give details of all countries of which you are a citizen
Country 1
I Voluntary declaration Yes No
Country 2
II Name, date of birth and passport verified Yes No
III Currency verified PART B - DETAILS OF TRAVEL
Yes No
IV Officers name 9 Direction of travel OUT OF Australia INTO Australia

10 What is the name of the Australian city/town where you are clearing
Customs?
V Name of port

VI Date D D MM 2 0 Y Y 11 Arrival OR departure date D D MM 2 0 Y Y


VII Infringement notice number 12 Flight number or name of ship

SENSITIVE (when complete) CBM-PC(C) Form 53 (JUN2015)


SENSITIVE (when complete)

PART C DETAILS OF CURRENCY BEING CARRIED


13 Where is the foreign (not Australian) city and country that the currency is being imported from OR taken to?
City
Country

14 Give details of the currency being carried to the nearest whole number
Currency Currency
Code Amount of Currency Code Amount of Currency

A U D

If more than 8 currencies, attach extra details on a separate sheet


15 Are you carrying this currency on your own behalf? Yes Go directly to Part F No Continue with Part D

PART D IF NOT YOUR OWN, ON WHOSE BEHALF ARE YOU ACTING?


16 What is the full name of the person, business or organisation on whose behalf you are acting?

17 Business/residential address of this person, business or organisation (cannot be a P.O. Box)

State Postcode
Country Phone No
(if not Australia)

18 Occupation, business or principal activity of this person, business or organisation ACN, ABN or ARBN

PART E IF NOT FOR YOURSELF, TO WHOM ARE YOU DELIVERING THE CURRENCY?
19 What is the full name of the person, business or organisation to whom the currency is being delivered?

20 Business/residential address of this person, business or organisation (cannot be a P.O. Box)

State Postcode
Country Phone No
(if not Australia)

21 Occupation, business or principal activity of this person, business or organisation ACN, ABN or ARBN

PART F DECLARATION AND SIGNATURE AUSTRAC USE ONLY


22 The information I have given in this form is true, accurate and Comments
complete. .
I understand criminal or civil penalties may apply for giving false or
misleading information, or for failing to supply information.

Signature
SIGN
HERE

Date D D MM 2 0 Y Y

SENSITIVE (when complete) CBM-PC(C) Form 53 (JUN2015)