Fincen Form 110 (8-2005) - Designation Of Exempt Person
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1
2Designation of Exempt Person
110
FinCEN Form
Previous editions will not be accepted after September 2011
Please type or print. Complete all parts that apply.
March 2011
OMB No.1506-0012
See instructions.
Send your completed form to: IRS Detroit Computing Center, Attn: Designation of Exempt Person, P. O. Box 33112, Detroit, MI 48232-0112
Part I
Filing Information
1 Indicate the type of filing by checking a, c, or d (check only one)
a
Initial designation
c
Exemption amended
d
Exemption revoked
2 Effective date of the exemption
__________ / __________ / __________
MM
DD
YYYY
Part II
Exempt Person Information
4 Doing business as (DBA)
3 Legal name of the exempt person
5 Address
*9 EIN or SSN
7 State
8 ZIP Code
6 City
10 Type of exempt person, check box c, d, e, or f (check only one)
c
Listed company
d
Listed company subsidiary
e
Eligible non-listed business
f
Payroll customer
Part III
Filer Information
11 Name of bank
12 Address
15 ZIP Code
14 State
16 EIN
13 City
17 Indicate the bank’s primary federal regulator by
a
OCC
b
FDIC
c
FRS
d
OTS
e
NCUA
f
IRS
checking a, b, c, d, e, or f (check only one)
18 If this designation is also being made for one or more affiliated banks, check this box.
See Part V of the instructions for the procedure for listing additional affiliated bank(s).
Part IV
Signature
I am authorized to sign this form on behalf of the bank granting the exemption and any listed bank subsidiaries. I declare that the information
provided is true, correct and complete.
19 Signature
20 Print name
23 Telephone number - (include area code)
22 Date of signature
21 Title
_____ / _____ / _______
(
)
MM
DD
YYYY
If filing this form as a paper submission, please mail to the following address:
IRS Detroit Computing Center
Attn: Designation of Exempt Person
P.O. Box 331 12
Detroit, MI 48232-0112
Catalog Number 47385C
Rev. 03/11
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