Currency Transaction Report By Casinos - Nevada
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48852
Currency Transaction Report by Casinos—Nevada
Form
(May 1997)
OMB No. 1506-0003
Please type or print.
Use this form for transactions occurring after April 30, 1997.
Department of the Treasury
(Complete all applicable parts—see instructions)
Internal Revenue Service
1
Check appropriate box(es) if:
a
Amends prior report
b
Supplemental report
Part I
Person(s) Involved in Transaction(s)
Section A—Person(s) on Whose Behalf Transaction(s) Is Conducted (Patron)
2
Multiple persons
3
Individual’s last name or Organization’s name
4
First name
5
M.I.
6
Permanent address (number, street, and apt. or suite no.)
7
SSN or EIN
8
City
9
State
10
ZIP code
11
Country (if not U.S.)
12
Date
M
M
D
D
Y
Y
Y
Y
of
–
birth
13
Method used to verify identity:
a
Examined identification credential
b
Known patron - information on file
c
Organization
d
Other
14 Describe identification credential:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
d
Other
e
Issued by:
f
Number:
15 Customer account number
Section B—Individual(s) Conducting Transaction(s)—If other than above (Agent)
16
Multiple agents
17
Individual’s last name
18
First name
19
M.I.
20
Permanent address (number, street, and apt. or suite no.)
21
SSN
22
City
23
State
24
ZIP code
25
Country (if not U.S.)
26
Date
M
M
D
D
Y
Y
Y
Y
of
–
birth
27
Method used to verify identity:
a
Examined identification credential
b
Known patron - information on file
c
Other
28
Describe identification credential:
a
Driver’s license/State I.D.
b
Passport
c
Alien registration
d
Other
e
Issued by:
f
Number:
Part II
Amount and Type of Transaction(s) (Complete Box 31 or 32)
29
Multiple transactions
30
Dissimilar transactions
31
CASH IN: (in U.S. dollar equivalent)
32
CASH OUT: (in U.S. dollar equivalent)
a
Purchase of casino chips, tokens,
Redemption of casino chips, tokens,
a
$
.
$
.
and other gaming instrumentalities
and other gaming instrumentalities
.
.
b
Deposit (front money or safekeeping)
b
Withdrawal of deposit (front money or safekeeping)
.
.
c
Payment on credit (including markers)
c
Advance on credit (including markers)
.
.
d
Table game cash bet lost
d
Payment on bet (including slot jackpot)
.
.
e
Non-table game cash bet
e
Currency paid from wire transfer in
.
.
f
Other (specify)
f
Negotiable instrument cashed (including checks)
.
g
Travel and complimentary expenses and gaming incentives
.
h
Payment for tournament, contest, or other promotions
.
i
Other (specify)
$
$
.
.
g
Enter Total Amount of CASH IN transaction
j
Enter Total Amount of CASH OUT transaction
33
Date of transaction
M
M
D
D
Y
Y
Y
Y
34
Time of transaction
35
Foreign currency used
A.M.
(see instructions)
: — —
(country)
P.M.
— —
36
Additional Information
Casino Reporting Transaction(s)
Part III
37
Casino’s trade name
38
Casino’s legal name
39
Employer identification number (EIN)
40
Address (number, street, and apt. or suite no.) where transaction occurred
41
Contact telephone number
(
)
42
City
43
State
44 ZIP code
45
Country (if not U.S.)
–
46
Name and title of recorder/handler
47
Signature of recorder/handler
48
Date
M
M
D
D
Y
Y
Y
Y
of
signature
Sign
Here
49
Name and title of reviewer
50
Signature of reviewer
51
Date
M
M
D
D
Y
Y
Y
Y
of
signature
8852
For Paperwork Reduction Act Notice, see page 2.
Cat. No. 23511I
Form
(5-97)
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